Vol 17, No 2 (2015)

Primary clinical examination of the patient with dizziness conducted in a short time does not require special equipment and can quickly reveal the supposed cause of vestibular disorders, which is necessary to determine the subsequent examination and treatment algorithm. The article presents a sample of the methods used in otoneurologist practice, which, according to the authors, are sufficient for initial diagnosis, and being the simplest in execution, do not require time-consuming and complex equipment, in other words, are available for any specialty physician during the examination of the patient with dizziness in the conditions of outpatient visits. The detailed review of the methodology and evaluation of such tests as the study of spontaneous nystagmus when looking straight and abduction sight, saccades, smooth pursuit, optokinetic test of the head rotation, dynamic visual acuity, head shaking test, the positional tests for benign paroxysmal positional vertigo, Romberg test, Unterberger test, demonstrative tests and others.

The purpose of clinical supervision is to demonstrate a case of severe congenital myopathy and liver injury for patient of older age, that took statins (simvastatin) for a long time; to discuss the algorithm of management of patients with suspected pathology of the muscular system (rhabdomyolysis); in order to draw the attention of physicians to the need for a thorough and detailed examination of the patients with persistent high numbers creatinephosphokinase (CPK) and transaminase blood after discontinuation of statins to exclude more rare diseases - congenital myopathies. This clinical case demonstrates the development of hereditary myopathy, which for a long time, masked itself as statininduced myopathy pathology.Peculiarities of the clinical observations. The patient with high numbers of cholesterol (LDL) had been prescribed statins. During 4 years (since 2006), she regularly took these drugs and controlled biochemical parameters of blood, which remained within normal values, the cholesterol level was normalized. For the last year before admission to the Clinic of internal diseases named after Vasilenko for survey about different diseases, she has received many drugs that enhance hepatotoxic and myotoxicity action of statins. Since 2010, the patient noted the emergence of gradually increasing neurological symptoms. 6-7-fold increase in transaminases was marked in the blood during this period. For a long time, the patient was not studied CPK level, when myopathy was suspected first time, the CPK level was 13 upper limits of normal. But even after discontinuation of statins the CPK level had not normalized, but had continued steadily to increase. Differential diagnosis was conducted and possible diseases with increased levels of transaminases and CPK were excluded. According to the algorithm for management of patients with suspected statininduced defeat muscular system, the patient had been conducted electroneuromyography, liver biopsy and skeletal muscle, resulting in the unlikelihoodof statininduced myopathy as a diagnosis. Positron emission tomography and studied the tumor markers were conducted for patient to exclude a paraneoplastic process. Data for cancer process hadnot been received. Finally, the patient had been sent to the Research center of neurology RAMS, where the following diagnosis had been formulated after a survey: "oculopharyngeal muscular dystrophy" (hereditary-degenerative disease characterized by progressive muscular weakness and atrophy).Conclusion. As of today, statins are an integral component of primary and secondary prevention and treatment of cardiovascular diseases and their complications. This class of drugs confirmed and proved its effectiveness and safety by multicenter studies. However, making a decision about the need for statin use, the nature of their regime and dose, it is necessary to consider their interactions with other prescribed drugs, characteristics of the patient, which can increase the risk of statin induced myopathy. In addition, assessing the potential risk of adverse effects of statins, preference must be given to hydrophilic statins with the lowest risk of toxic effects on hepatobiliary and muscular system.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as metamizole (Analgin), paracetamol (acetaminophen), flupirtine, anticonvulsants, antidepressants and local anesthetics are widely used for the treatment of different pathogenetic types of pain. Means for selecting a pain treatment should take into account the presence of concomitant diseases of the gastrointestinal tract, the cardiovascular system, etc. Currently, the medical practitioner is required to «balance» between gastroenterology and cardiovascular safety of NSAIDs or search for drugs outside of this class. Flupirtine is a proof of informed choice of analgesic depending on the particular clinical situation.

Mild cognitive impairment (MCI) is commonly known by an impaired memory and other higher brain functions, as a rule, demonstrated in elderly persons who are outside the age-related standard range, but do not lead to social exclusion, by not causing dementia. MCI are a polyetiologic syndrome that may develop within a wide range of neurological diseases. Most often a clinical MCI diagnosis of the syndrome matches the pathological markers of neurodegeneration and cerebral vascular insufficiency. It has been shown that clinical and subclinical orthostatic hypotension are associated with impaired cognitive function, decreased activity, motivation and an increased risk of dementia, diabetes and Parkinson's disease. Pronoran (piribedil) combines the dopaminergic and noradrenergic properties; its effectiveness has been studied and has been proven in more than 15 clinical studies, which were attended by a total of more than 7 thousand patients from around the world.

The article is devoted to the actual problem - the role of discogenic factor in the development of low back pain. Presented is an updated description of CTF- classification of pathological changes of discs (2014) and MSU-classification of disc herniation. We discuss the pathogenesis, clinical manifestations, diagnosis and additional differential treatment (conservative and operative) of the two most common manifestations of discogenic lumbar pathologies: axial discogenic pain and disco-radicular conflict. Emphasized is the role of inflammation in the development, maintenance of discogenic pain and regression of herniated disc. Materials presented the first evidence-based guidelines for the diagnosis and treatment of disc herniation with radiculopathy symptoms of the expert group North American Spine Society's - NASS (2012). Discussed are also the treatment of discogenic pain, selection of optimal drug groups.

Osteoarthritis is the most common disease among the diseases of the musculoskeletal system. The main antiarthrosis drugs are similar in structure of cartilage of tissue-chondroitin sulfate and glucosamine, the mechanism of which is based on increasing the synthesis of proteoglycans and hyaluronic acid, reducing apoptosis of chondrocytes inhibiting the synthesis of aggressive metalloprotease. The article presents research data show the effectiveness and safety of a combined preparation Teraflex, , analgesic effect which is not inferior to non-steroidal anti-inflammatory drugs. The possibility of NSAIDs dosage decrease with Theraflex Advance being prescribed for minimizing the pain in osteoarthritic patients.