Vol 21, No 12 (2019)

The guidelines “Nodular goiter” present the key points of epidemiology and pathogenesis, modern diagnostic concept of diagnosis and differential diagnosis of various morphological variants of thyroid nodules. Standardized classifications of nodular goiter ultrasound and cytological diagnosis are demonstrated. Methods of radical treatment optimization are discussed. Guidelines are supplemented with supporting material and algorithm of diagnosis and treatment of these patients. Recommended for endocrinologists, ultrasound medical specialists, clinical laboratory medicine specialists, radiologists, surgeons, and general practitioners use.

Obesity is a chronic disease associated with an excessive fat accumulation in the body. The increasing prevalence of obesity and developing of its comorbid diseases dictate the need for a precise diagnosis based on disease history, physical and laboratory-instrumental examinations.

Combination of traditional cardiovascular risk factors with specific risk factors of early development and quick progression of atherosclerosis including first of all hyperglycemia is typical in patients with diabetes mellitus (DM). The results of large clinical trials ADVANCE, ACCORD and VADT definitely proved the role of glycemia control in prevention of microvascular complications of DM. In some studies it was proven that parameters of glycemic variability (GV) are significant in prognosing diabetic retinopathy, nephropathy and cardiovascular complications. The role of hyperglycemia in development of microvascular complication in patients with DM type 2 is not clear at present. Modern approach to DM management as one of the most important methods of micro and macroangiopathies prevention includes necessary glucose self-control. Glycemia self-control should be precise, easy and comfortable letting the patient to have effective and safe hypoglycemic therapy. Choice of glucometer is one of the main aspects of blood glucose self-control. From the point of view of the doctor the most important criteria for glucometer choice is its conformance to standards of accuracy, and from the patient’s point of view - its convenience and ease in use. Because of technological advancements the accuracy of blood glucose level test increases and the procedure of glycemia self-control becomes easier that results in increase of adherence to treatment and hypoglycemic therapy effectiveness. Achievement and sustenance of glycemia target level, prevention of micro and macroangio-pathic complications are impossible without full active participation of the patient in DM treatment and blood glucose self-control with the use of precise and convenient for the patient glucometer such as Contour Plus One.

The article discusses influence of long-term combined therapy including Mildronate and angiotensin-converting enzyme inhibitor ramipril at endothelium function and heart and vessels morphofunctional state.In recent time cytoprotectors pharmacodynamics of which is characterized by switching cell energy exchange from fatty acids acidification to a more advantageous for oxygen preservation metabolism way - predominant glucose utilization, became more widely used in clinical cardiology practice. At present there are multiple literature reports on effective cytoprotectors use in complex treatment of hypertension. Among cytoprotectors real clinical effects are described in Mildronate. Considering that remodeling processes of left ventricle myocardium and vessel wall are accompanied by free-radical oxidation activation and energy exchange disturbance, and many effects of antihypertensive medications are realized directly through nitrogen oxide system and are associated with vascular endothelium function which are affected in patients with hypertension, Mildronate use in complex treatment of this disorder in patients with ischemic heart disease (IHD) seems to be appropriate. Aim. To determine influence of Mildronate in combination with antihypertensive therapy with angiotensin-converting enzyme inhibitor on severity of left ventricle myocardium hypertrophy, its systolic and diastolic function, intima-media complex thickness in arteria carotis communis, and endothelium dependent vasodilation of brachial artery in patients with hypertension combined with IHD. Materials and methods. The study included 50 patients with stage II hypertension of medium severity. The patients were randomized into 2 groups, 25 patients in each. Ramipril was used for blood pressure decrease. Monotherapy with ramipril was conducted in both groups for 3 weeks. From 21 st day of follow-up peroral Mildronate 500 mg 2 times daily was added to the treatment in study group. The medication was used without interruption for 6 months and then in series of treatment for 2 months with 2 months intervals, the total follow-up period was 24 months. Control group patients received monotherapy with ramipril. Results. It has been established that Mildronate use in combination with traditional antihypertensive therapy with angiotensin-converting enzyme inhibitor ramipril had positive impact on left ventricle hypertrophy severity, systolic and diastolic function, severity of endothelium dysfunction, and intima-media complex thickness in arteria carotis communis that shows promise for Mildronate use in combined treatment of hypertension in patients with IHD. Also the effects of Mil-dronate use are most prominent after long-term systematic use.

Aging is a process of changing living systems in time, causing disturbances in their structure and functions, which lead to decrease in the reserve capacity of most systems of the human body and is accompanied by related comorbidities, as well as an increase in mortality. The modern theory of pathogenesis of aging is called inlammaging, originated from the English inflammation - inflammation and aging - aseptic, sterile, mild inflammation that is responsible for processes of aging and age-related comorbidities including osteoarthritis, one of the most common diseases among elderly patients. Drugs, which help to slow down the progression of inflammation and used in combination with non-pharmacological methods of prevention of this condition belong to the group of so-called anti-age medicine, as they reduce the severity of age-related problems and syndromes, as well as contribute to the maintenance/improvement of the functional status of the patient. One of these drugs is Alflutop, which contains a combination of components that have an anti-inflammatory effect on osteoarthritis and inflammaging. This article highlights pathogenetic mechanisms of inflammation caused by aging and osteoarthritis, as well as the points of application of the pharmacological action of the components of the drug Alflutop.

The article provides information about the place of ezetimibe in the latest edition of the joint recommendations of the European Society of Cardiology and the European Atherosclerosis Society of 2019, dedicated to the correction of lipid metabolism disorders in order to prevent and treat clinical complications of atherosclerosis. The material of the recommendations is discussed from the point of current conception of the effectiveness and safety of the inhibitor of intestinal absorption of cholesterol - ezetimibe, which is widely used in combined lipid-lowering therapy. The features of the use of ezetimibe in combination with statins to achieve target lipid levels and reduce the frequency of side effects of first-line drugs are detailed. New approaches to stratification of cardiovascular risk in European and Russian recommendations for the diagnosis and treatment of atherogenic dyslipidemia are compared. The possibilities of combined lipid-lowering therapy to achieve new target levels of low density lipoprotein cholesterol in patients with high and very high cardiovascular risk are discussed.

Background. In recent years, interest in metabolic therapy with myocardial and cerebral cytoprotectors has increased. Given the results of clinical studies of levocarnitine, indications for its use are clarified and the therapeutic niche of this drug is established in patients with coronary heart disease (CHD) and chronic heart failure (CHF) with cardiogenic encephalopathy. Aim. To study an efficacy and safety of a metabolic drug levocarnitine in the treatment of patients with coronary artery disease complicated by chronic heart failure with preserved ejection fraction (CHF-pEF) and cardiogenic encephalopathy. Materials and methods. In the open comparative study 120 patients with stable angina pectoris of II-III functional class (FC) associated by CHF-pEF of II FC were divided into 2 groups which were comparable by age and gender. In one group, Elkar® solution for intravenous and intramuscular administration, manufactured by «ПИК-ФАРМА» (Russia) 100 mg/ml was prescribed in addition to the standard therapy. To evaluate cognitive indexes a brief scale of assessment of mental status (Mini-Mental State Examination) was used. Results. In the group treated with levocarnitine, there was a significant improvement in cognitive indexes compared with the control group, as well as a beneficial effect on the left ventricle diastolic function and exercise tolerance was identified. Conclusions. Levocarnitine is an adjunct (to the basic treatment of CHD and CHF) effective metabolic drug with cardio- and cerebroprotective effects in the treatment of patients with CHD, complicated by CHF-pEF and cardiac encephalopathy. It proved to be a safe, well-tolerated drug.

The end of 2018 and the beginning of 2019 were marked by 2 important events in medicine, namely the release of new European and Russian guidelines for the management of arterial hypertension. For most patients, fixed combinations of antihypertensive drugs are recommended as first step treatment. Today, in the Russian Federation, despite the variety of fixed drug combinations there are combinations that are effective, meet the latest recommendations, but are not currently presented in fixed form, for example, a combination of indapamide and angiotensin II receptor blocker. Indapamide not only effectively reduces blood pressure, but also has a number of organoprotective effects (cerebro-, cardio- and nephroprotective). The data of PROGRESS (Perindopril protection against Recurrent Stroke Study) and PATS (Post-stroke Antihypertensive Treatment Study) studies on indapamide provided the basis of American recommendations for the secondary prevention of stroke, and HYVET-COG (Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment) study showed a decrease in the risk for dementia in patients treated with indapamide. These data, along with the results of other placebo-controlled studies, were included in the meta-analysis mentioned above, a statistically significant decrease in a risk of dementia was noted in the “antihypertensive treatment” group compared to placebo. Angiotensin II receptor blockers also have marked organoprotective effect and a large evidence base on their ability to reduce the risk for coronary and cerebrovascular (stroke, dementia) complications. One more effective unfixed drug combination that is not registered on the market is a combination of nitrendipine and indapamide, which can be effectively used not only to lower blood pressure, but also to prevent dementia, including in Alzheimer's disease. Thus, although the new European and Russian guidelines give preference to fixed combinations of antihypertensive drugs, there are clinical situations where it seems appropriate to consider prescribing unfixed combinations of antihypertensive drugs.

In a form of a clinical lecture the article presents data on significance of purine metabolism disorders in pathogenesis of some frequent internal diseases and uric acid nephrolithiasis, their incidence and meaning in modern medical practice. On the basis of most modern data on pathogenesis of purine metabolism disorders its diagnosis and treatment with xanthine oxidase inhibitors, aspects of allopurinol treatment and advantages of the most modern medication febuxostat are described. From urologist point of view a tight pathogenic association of purine metabolism disorders with development of uric acid nephrolithiasis, diet therapy and medical treatment are rationalized including hyperuricemia correction with xanthine oxidase inhibitors.