Alesya A. Klimenko

The article discusses digital technologies as an integral part of the modern higher medical education system. Attention is focused on electronic educational platforms, virtual patients, interactive clinical scenarios, multimedia simulators, and other tools that expand access to educational materials, standardize specific elements of training, and ensure the monitoring of academic performance. We analyzed the role of the digital educational event and the potential of its design within the pedagogical process, as well as the necessity of developing clinical AI literacy among students. Special attention is given to the use of electronic learning management systems at the final stage of training to build the practical readiness of General Medicine graduates. An example of using a digital educational environment as a tool for developing follow-up care skills in future physicians is presented.

Among the multidisciplinary medical issues facing rheumatology as a branch of internal medicine, a central place is occupied by cardiovascular diseases (CVD) associated with atherosclerotic vascular disease (ASCVD); these – as in the general population – are the leading causes of mortality and the most common forms of comorbidity. Chronic inflammation, regarded as a central mechanism in the pathogenesis of both systemic autoimmune rheumatic diseases (SARDs) and CVDs, is associated with shared genetic and environmental factors. Alongside ASCVD and peripheral artery disease, heart failure and arterial hypertension are common forms of comorbid cardiovascular pathology in SARDs, whereas pericarditis, endocarditis, other forms of valvular heart disease, arrhythmias, coronary vasculitis, pulmonary arterial hypertension, myocarditis, inflammatory cardiomyopathy, and aortic aneurysm and dissection are considered systemic manifestations of SARDs. Data from large-scale epidemiological population studies, registries, databases, and their meta-analyses regarding CVD risk in SARDs indicate an increased risk of cardiovascular pathology in patients with autoimmune diseases – particularly those under the age of 45 – which is associated with a higher need for hospitalization and increased mortality. The development of ASCVD in patients with SARDs is associated not only with traditional cardiovascular risk factors but also with clinical parameters and laboratory and instrumental biomarkers reflecting immune dysregulation, inflammatory activity, and endothelial dysfunction. Chronic subclinical (low-grade) inflammation plays a fundamental role at all stages of ASCVD progression: vascular endothelial dysfunction; induction of endothelial cell apoptosis; synthesis and modification of lipoproteins, including low-density lipoproteins and apolipoprotein(a); formation of “foam” cells; rupture of the atherosclerotic plaque; and development of atherothrombosis. A wide range of anti-inflammatory drugs with diverse mechanisms of action has currently been developed for the treatment of SARDS; their efficacy is linked to the inhibition of the synthesis or signaling of pro-inflammatory cytokines, and the cardiovascular effects of these drugs in the context of SARDS and cardiovascular diseases are the subject of intensive research. A wide range of clinical and fundamental issues common to both cardiology and rheumatology has led to the emergence of a new field – cardiorheumatology – which integrates these issues within a multidisciplinary specialty dedicated to the comprehensive study of the role of inflammation in the development of cardiovascular and rheumatic diseases. In Russia, the study of issues in cardiorheumatology – using rheumatic heart disease as a model – began as early as the mid20th century. Academician A.I. Nesterov was a pioneer in this field, playing a foundational role in the establishment of the Institute of Rheumatology (1958) and the cardiorheumatology service in Russia; he was later succeeded in this work by Academicians E.I. Chazov and V.A. Nasonova. Global experience and Russia’s rich traditions in studying the immunopathology of cardiovascular diseases and SARDs create a solid foundation for expanding multidisciplinary research in the field of cardiorheumatology in Russia.

Aim . To evaluate the association of type 2 diabetes mellitus (DM) with the risk of all-cause mortality in patients with calcific aortic stenosis (CAS). Material and methods . A prospective cohort study was conducted. Out of 95 patients initially recruited for the study, 71 patients with CAS aged 55 years and older hospitalised in the therapeutic and cardiology departments of two Moscow hospitals in 2023-2026 were included in the final analysis: 36 patients with type 2 DM and 35 without DM. Patients with a history of acute rheumatic fever were excluded from the study. All participants underwent clinical, laboratory, and echocardiographic examinations. After discharge, information on the patients’ condition was obtained by telephone interview and review of outpatient records. The primary endpoint was all-cause mortality. Survival analysis was performed using the Kaplan–Meier method and Cox regression. The median follow-up period was 538 [408; 670.5] days. Results . All-cause death was recorded in 11 of 36 (30.6%) patients with DM and in 5 of 35 (14.3%) patients without DM (p=0.155); the differences in survival curves did not reach statistical significance (log-rank test, p=0.137). In the univariate Cox model, type 2 DM did not demonstrate a statistically significant association with the risk of death (hazard ratio (HR) 2.192; 95% confidence interval (CI) 0.760–6.323; p=0.147); in the two-variable model adjusted for high-density lipoprotein cholesterol levels, the result also remained non-significant (HR 1.705; 95% CI 0.580–5.013; p=0.333). Patients with DM had a higher functional class of chronic heart failure (p=0.033), a lower left ventricular ejection fraction (p=0.016), and a higher wall motion score index (p=0.023); CAS severity parameters did not differ significantly (p=0.786). Conclusion . In the study sample, a statistically significant association between type 2 DM and the risk of death was not established. The numerically higher mortality rate and wide CI do not allow excluding a clinically significant effect. The results should be considered exploratory and require confirmation in studies with a larger sample size.

Aim . To summarize the findings of studies investigating the clinical and prognostic significance of cardiac autonomic dysfunction (CAD) in patients with systemic sclerosis (SSc) in a systematic review. Material and methods. A literature search was performed in the eLIBRARY.ru and MEDLINE (PubMed) electronic bibliographic databases. The systematic review was reported in accordance with the PRISMA guidelines. No restrictions on the year of publication were applied during the literature search and study selection. A qualitative synthesis of the findings was performed. Results . The review included 29 studies reported in 32 publications. The number of patients with SSc ranged from 10 to 86. Two publications described prospective studies, whereas the remaining studies had a cross-sectional design. CAD was primarily assessed by heart rate variability (HRV) analysis; Ewing cardiovascular autonomic tests, questionnaires, and heart rate turbulence (HRT) analysis were used less frequently. Most studies demonstrated reduced time- and frequency-domain HRV indices, impaired parasympathetic regulation, and a relative predominance of sympathetic activity in patients with SSc. CAD parameters were associated with diffuse cutaneous disease, the severity of skin and microvascular involvement, pulmonary hypertension, structural and functional cardiac abnormalities, and ventricular arrhythmias. In several studies, reduced HRV and abnormal HRT parameters were associated with adverse outcomes. Conclusion . CAD in patients with SSc is characterised by impaired parasympathetic regulation, a relative predominance of sympathetic influences, reduced HRV, and abnormal HRT parameters. CAD indices were associated with clinical and laboratory characteristics of SSc reflecting disease severity and activity. The available evidence suggests that CAD may have adverse prognostic implications in patients with SSc, which requires further investigation in large prospective studies.

Objective. To identify and develop criteria for the tonsillogenic nature of reactive arthropathies in patients with chronic tonsillitis (CT). Material and methods. This prospective cohort study enrolled 150 patients with CT aged 18 to 35 years. The main group (Group I, n=75) consisted of patients with CT and arthralgia, the control group (Group II, n=75) included patients with CT without joint syndrome. All patients underwent questioning, clinical and laboratory examination (including CRP, ASL-O, RF, ACCP, ANA on HEp-2 cells, EBV IgG, vitamin D). When indicated, joint radiography was performed. Patients with confirmed tonsillitis-associated arthropathy (n=69) underwent bilateral tonsillectomy (TE) with histological examination of the tonsils and follow-up assessment after 6 months. Results. Patients with CT and arthralgia had a significantly more severe tonsillar history (frequent sore throats, paratonsillitis), and more often suffered from intoxication syndrome and low-grade fever (p<0.05). In the main group, elevated levels of CRP (36% vs. 20%), ASL-O (37% vs. 19%), vitamin D deficiency (32% vs. 11%), as well as serological markers of EBV reactivation (IgG to VCA and EBNA; OR up to 21.7) and autoimmune activity (ANA ≥1:160 in 32% vs. 11%; OR=4.44) were significantly more frequent. Six months after TE, joint syndrome resolved in all operated patients, with a significant decrease in CRP, ASL-O, ANA titers, and normalization of vitamin D levels (p<0.001). A diagnostic algorithm was developed to differentiate tonsillitis-associated arthropathies from rheumatic diseases. Conclusion. Chronic tonsillitis can be a cause of systemic joint syndrome. Bilateral tonsillectomy is an effective pathogenetic treatment for these patients. The proposed clinical and laboratory criteria optimize diagnosis and patient selection for surgical treatment.

Physician training requires a unified approach to the content of educational programs across the country’s various medical universities in order to standardize the vo­lume of knowledge that underlies professional skills, abilities, and competencies. To improve the preparation of medical students for practice, creation of a unified educational program for studying the interdisciplinary concept of cardiovascular-renal-hepatic-metabolic (CRHM) syndrome within the General Medicine program is discussed. This article presents methodological materials allowing pedagogical explanation of the concept, pathogenesis, characteristics of cardiometabolic risk factors, and individual components of CHRM syndrome in fundamental and clinical departments using the end-to-end learning principle. In this regard, the role of fundamental disciplines lies in shaping the curriculum in accordance with the needs of clinical practice. Special attention is given to teaching diagnostic criteria for the syndrome and a set of personalized preventive measures depending on the stage and phenotype of CHRM syndrome. It is proposed to emphasize the transition from target organs to a unified metabolic phenotype, taking into account the multi-vector nature of CHRM syndrome processes. The inclusion of the CHRM syndrome in the curricula of the Oncology, Neurology, Rheumatology, and Obstetrics and Gynecology disciplines appears promising, allowing future practicing physicians to perceive this concept holistically and systemically.

Background . Despite the integration of imaging methods such as ultrasound and magnetic resonance imaging for the detection of enthesitis, clinical assessment remains the foundation of diagnosis in both everyday practice and clinical studies. However, the frequency of detecting enthesitis in patients with psoriatic arthritis (PsA) varies considerably, which may be primarily due to differences in assessment methods. The aim – to evaluate the frequency of enthesitis in patients with psoriatic arthritis using modern assessment scales and to investigate the association between enthesitis measures and disease characteristics. Materials and methods . This cross-sectional study included 116 patients with PsA diagnosed according to the CASPAR (ClASsification for Psoriatic ARthritis) criteria. Enthesitis was assessed using the Leeds Enthesitis Index (LEI), the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), the Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC), and a combination of these indices. Results . A total of 96 (82.8%) patients had at least one tender enthesis. Among these, 47 (49%) patients had tenderness at 1–3 entheses (1 enthesis – 19.8%; 2 entheses – 18.8%; 3 entheses – 10.4%), while the remaining patients had tenderness at 4 or more entheses. The median values of the indices were as follows: LEI – 1.0 [0.0; 2.25], SPARCC – 3.0 [1.0; 5.25], MASES – 1.0 [0.0; 2.0]. The frequency of enthesitis (at least one tender enthesis) according to each index was: LEI – 60 (62.5%) patients, MASES – 61 (63.5%) patients, SPARCC – 84 (87.5%) patients. In 9 (9.4%) patients, MASES identified one or more enthesitis sites, whereas no tender entheses were detected by SPARCC or LEI. A moderate positive correlation was found between body mass index (BMI) and the SPARCC index ( ρ =0.32; p =0.001). Patients with normal BMI had lower values for the number of tender entheses (3 [1; 5] vs. 4 [2; 10]; p =0.043), the SPARCC index (2 [1; 3] vs. 3 [1; 6]; p=0.025), and the combined SPARCC + MASES index (4 [1; 11] vs. 6.5 [5; 11]; p=0.034). Conclusion . Enthesitis is present in a significant proportion of patients with PsA (82.1%). To improve the detection rate of enthesitis in patients with PsA, the combined use of the SPARCC and MASES indices is preferable.

Antiphospholipid syndrome (APS) is defined as “an autoimmune thromboinflammatory disease characterized by an increased risk of thrombosis localized in the venous and arterial vascular beds, thrombotic damage to microvessels, placental insufficiency, cytopenia, skin and heart valves lesions, nephropathy, pulmonary hemorrhages, etc.”. Long with clinical symptoms, the cardinal hallmark of APS is antibodies to phospholipids and phospholipid-binding proteins and including lupus anticoagulant, antibodies to cardiolipin, and antibodies to β2-glycoprotein I, highlighting the leading autoimmune mechanism of this pathogenesis. APS is considered an important problem in modern medicine, located at the intersection of rheumatology and hematology. A distinctive feature of APS is heterogeneity, which manifests itself both at the clinical (phenotypes, course variants) and pathogenetic levels (molecular endotypes). Particular attention is drawn to the potentially lethal form of APS, manifested by the fulminant development of multiorgan thrombosis, which was first identified by Ronald A. Asherson in 1992 as the “catastrophic” form of APS (CAPS). Currently, approaches to personalized therapy of APS using artificial intelligence and, on this basis, the implementation of the concept of “treat-to-target” aimed at achieving remission, which in APS should be considered as the absence of recurrent thrombosis, are being actively discussed. The implementation of this strategy in autoimmune rheumatic diseases has largely become possible thanks to the development and introduction of a wide range of biologics, which are monoclonal antibodies or hybrid molecules that selectively modulate key mechanisms of immunopathogenesis. The clinical forms of CAPS and the pathogenetic mechanisms of APS are considered, and on this basis, new possibilities for the treatment of CAPS using anti-B-cell therapy, complement inhibitors (eculizumab), prospects for the prevention of thrombosis associated with comorbid cardiometabolic pathology.

Generalized osteoarthritis (GOA) is a clinical variant of osteoarthritis characterized by multiple joint involvement, including the joints of the hands, knees, hips, and the spinal joints. This article presents the evolution of the knowledge about GOA from the classic works of J.H. Kellgren and R. Moore (1952) to modern approaches addressing multi-joint osteoarthritis. Various definitions of multi-joint osteoarthritis are analyzed, demonstrating their dependence on the number of involved joint groups and their impact on the assessment of disease prevalence. Special attention is paid to the axial component of GOA: involvement of intervertebral discs and facet joints is considered as a single clinical and morphological phenotype with common pathophysiological mechanisms (inflammation, angiogenesis, extracellular matrix remodeling). Current diagnostic approaches are presented, including clinical assessment, instrumental methods, and promising biomarkers. A phenotype-oriented approach to the treatment of GOA is substantiated.

Modern approaches to the treatment of patients with chronic thromboembolic pulmonary hypertension are based on a combination of pharmacotherapy and surgical methods. Transluminal balloon pulmonary angioplasty is a crucial interventional strategy, especially in patients who cannot undergo thromboendarterectomy or who experience residual pulmonary hypertension after surgery. Numerous studies have confirmed the high efficacy of transluminal balloon pulmonary angioplasty, demonstrating a significant reduction in pulmonary vascular resistance and pulmonary artery pressure. However, despite its proven therapeutic potential, the method is associated with the risk of serious complications. The most dangerous of these is lung ischemia-reperfusion injury, which can cause acute respiratory failure requiring mechanical ventilation or extracorporeal membrane oxygenation. Currently, preventive measures are being developed, including protocol improvements, stepwise dilation, use of intraoperative imaging, as well as preoperative administration of pulmonary hypertension-specific drugs. Effective and safe use of transluminal balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension requires strict patient selection, procedure performance in specialized centers, interdisciplinary decision-making, as well as readiness for timely diagnosis and management of complications in the early and late postoperative periods. Standardization of the procedure and development of algorithms aimed at reducing the risk of complications remain a promising direction.