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Резюме журнала Доктор.Ру за 2016 г. англ. версия

Doctor.Ru Gastroenterology No. 1 (118), 2016

Pancreatology: European News (following the Meeting of the European Pancreatic Club, Spain, 2015)

  1. B. Gubergrits, N. V. Byelyayeva, G. M. Lukashevich

Objective of the Review: To summarize the results of the main scientific studies in pancreatology conducted in 2014 and 2015.

Key Points: This article describes the achievements of leading European pancreatologists in studying the etiology, pathogenesis, risk factors, diagnosis and treatment of pancreatitis, tumors of the pancreas, and concomitant conditions.

Keywords: European Pancreatic Club, Ukrainian Pancreatic Club, chronic pancreatitis, pancreatic insufficiency, pancreatin.

Gastroesophageal Reflux Disease: Typical Treatment Problems and Approaches to Their Solution

  1. S. Bordin, S. V. Kolbasnikov, A. G. Kononova

Objective of the Review: To discuss the main pathogenic mechanisms underlying gastroesophageal reflux disease (GERD) and approaches to treating this condition.

Key Points: GERD results from gastroesophageal reflux that originates from the acid pocket. This paper outlines the action mechanisms of different pharmaceuticals used to treat GERD. The most effective treatments, the authors emphasize, are proton-pump inhibitors, which reduce the size and the damaging effects of the acid pocket. They specifically focus on treating refractory GERD. This paper describes the advantages of esomeprazole in achieving and maintaining remission in severe reflux esophagitis.

Conclusion: In GERD, poor response to therapy can be explained in several ways: These include incomplete reflux control by a proton-pump inhibitor and non-reflux mechanisms, which need to be identified and corrected, that lead to the development of symptoms.

Keywords: gastroesophageal reflux disease, pathogenesis, proton-pump inhibitors, esomeprazole.

Optical Biopsy in Detecting Changes in Gastric and Duodenal Mucosa

  1. A. Shavrov Jr., G. V. Volynets, A. A. Shavrov, M. M. Venediktova, A. G. Talalaev, S. G. Khomeriki

Study Objective: To assess the value of confocal laser endomicroscopy (CLE) in detecting changes in gastric and duodenal mucosa in children.

Study Design: This was a prospective, comparative study.

Materials and Methods: Between 2011 and 2014, 116 children, aged 3 to 18 with a confirmed underlying condition underwent another disease-specific examination at the Scientific Center of Children's Health. This examination included endoscopy combined with CLE and mucosa biopsy followed by histology. To determine the prognostic value of probe CLE in assessing non-affected and affected gastric and duodenal mucosa, optical biopsy results were compared to data obtained from standard histological examinations.

Study Results: For gastritis detection, the sensitivity and specificity of probe CLE were 83.7% and 87.5%, respectively; while its positive predictive value (PPV), negative predictive value (NPV), and accuracy were 93.9%, 70%, and 84.9%, respectively; and the Spearman's rank correlation coefficient (Rs) was 0.67 (р = 0.001). For duodenitis, the sensitivity and specificity of probe CLE were 86.7% and 81.8%, respectively; while its PPV, NPV, and accuracy were 90.7%, 75%, and 85.1%, respectively (Rs = 0.67, p = 0.001).

Conclusion: Using confocal endoscopy, endoscopy specialists can examine the mucous membrane at the cellular level in a real-time manner. Data obtained from this procedure can eliminate controversy between diagnoses based on endoscopic and histological findings. All this can make confocal endoscopy a leading intraluminal diagnostic method in pediatric gastroenterology and endoscopy.

Keywords: children, confocal laser endomicroscopy, optical biopsy, histology, stomach, duodenum.

Blood Parameters of Cell-Mediated Immunity in Patients with Atrophic Gastritis and Gastric Cancer

  1. A. Sinyakov, O. V. Smirnova, V. V. Tsukanov, E. V. Kasparov, A. V. Vasyutin

Objective of the Paper: To examine the specific features of blood immune cells in patients with atrophic body gastritis and gastric cancer (GC).

Study Design: This was a randomized, comparative study.

Materials and Methods: As part of an experiment, the authors examined 85 patients with moderate atrophic body gastritis, 25 patients with severe atrophic body gastritis, 50 patients with gastric cancer, and 90 apparently healthy subjects. All patients were aged 25 to 65. Diagnosis of atrophic gastritis included measurements of the serum levels of pepsinogen I, pepsinogen II, and antibodies against Helicobacter pylori; and morphological assessment of the gastric mucosa. Blood immune cells were assessed by an indirect immunofluorescence assay with monoclonal antibodies (CD3, CD4, CD8, and CD16).

Results: Compared to healthy study participants, patients with severe atrophic body gastritis and gastric cancer had lower counts of helper T-cells and killer T-cells, lower relative counts of natural killer T-cells, and a lower CD4+/CD8+ ratio.

Conclusion: Patients with atrophic body gastritis and gastric cancer had similar changes in their immune profiles, which led to secondary immunodeficiency.

Keywords: gastric cancer, atrophic gastritis, cell-mediated immunity, lymphocytes.

Pain and Dyspepsia Following Cholecystectomy

  1. A. Kutcheryavy

Objective of the Review: To systematize historical, pathophysiological, and clinical information about postcholecystectomy disorders in order to establish a framework for making strategic medical decisions for patients suffering from pain and dyspepsia after a cholecystectomy.

Key Points: Worldwide, cholecystectomy is one of the most common surgical interventions. After this surgery, at least half of all patients still have or will develop abdominal pain or dyspeptic symptoms; this is known as postcholecystectomy syndrome. In about half of all cases, postcholecystectomy pain and dyspepsia are explained by anatomical causes (distal common bile duct strictures, choledocholithiasis, acute pancreatitis, etc.). In other cases, these disorders are caused by functional abnormalities (sphincter of Oddi dysfunction, functional dyspepsia, duodenogastric reflux, and motility and functional bowel disorders) that require conservative treatment.

Conclusion: Postcholecystectomy pain and dyspepsia are caused by a wide range of anatomical and functional causes. The risk of these disorders increases in subjects who have pre-existing borderline mental illnesses and in young patients with preserved gallbladder function. To treat these abnormalities, most physicians prefer a combination medication therapy with spasmolytics as an essential component. For patients who remain unresponsive to this treatment after 3 months, possible options include endoscopic papillotomy and stent insertion into the common bile duct.

Keywords: cholecystectomy, postcholecystectomy syndrome, pain, dyspepsia, sphincter of Oddi dysfunction.

Diagnostic Value of Complex Elastography in Diffuse Liver Disease: Prospects and Potentials

  1. G. Morozova, A. V. Borsukov

Study Objective: To assess how diagnostic techniques are chosen for complex elastography in patients with diffuse liver disease (DLD).

Study Design: This was an open-label, randomized, comparative study.

Materials and Methods: We examined 124 patients with DLD (main group) and 58 people who didn't have DLD (control group). The study groups were randomized by gender, age, and underlying conditions. Complex elastography of liver parenchyma was performed in 58 patients in the control group and 119 patients in the main group. This examination included transient elastometry, compression elastography (transcutaneous examination or concurrently with endosonography), and shear-wave elastography.

Study Results: Complex elastography was used to measure the stiffness of liver parenchyma in healthy subjects. Measurements were taken of all liver segments, except segment VIII. This is because of its anatomical characteristics and the technical limitations of elastography techniques. The study showed statistically significant differences between the study groups in the parameters of complex elastography (p ≤ 0.05). However, elastometry parameters were similar in patients with steatosis and in healthy subjects (p > 0.01), too.

Conclusion: An assessment of liver-elastography parameters of healthy subjects helped standardize elastometry parameters in patients with DLD. The study results will allow specialists to combine instrumental diagnostic techniques and to modify the diagnostic algorithm. With different combinations of elastography techniques, the specificity of this diagnostic procedure can reach 98.9%; its sensitivity and accuracy can reach 95.1% and 96.9%, respectively.

Keywords: complex elastography, diffuse liver disease.

Alcohol and Changes in Intestinal Flora: Current Understanding

  1. G. Bakulin, N. V. Shalikiani

Objective of the Review: To outline the current thinking about ethanol's role in the progression of alcoholic liver disease due to changes it causes in intestinal flora.

Key Points: Alcohol can induce significant quantitative and qualitative changes in intestinal flora. It causes small intestinal bacterial overgrowth. Acetaldehyde — an intermediate product in ethanol metabolism — affects tight-junction and adhesion-junction proteins, thus reducing the barrier function of the intestinal wall. Another mechanism involved in an increased intestinal permeability is ethanolinduced activation of NO and О2 , production. These substances cause nitration and oxidation of tubulin and thus damage microtubules of the cytoskeleton. In alcohol abusers, qualitative changes in the flora composition manifest as an active growth of Gram-negative bacteria. These microorganisms produce endotoxins that activate hepatic macrophages and stimulate the production of pro-inflammatory cytokines (tumor necrosis factor-alpha and interleukins 1 and 6).

Conclusion: Experimental studies have shown that antibiotics and pre- and probiotics help reduce the increased intestinal permeability created by ethanol, the intensity of endotoxemia and thus the level of liver inflammation. This provides a new opportunity to use preparations that restore the intestinal microbiome as an effective therapy for alcoholic liver disease.

Keywords: alcoholic liver disease, endotoxemia, probiotics, small-intestinal bacterial overgrowth, dysbiosis.

Using Nitrofurans for Helicobacter Pylori Infection and Mixed Gastrointestinal Infections

  1. L. Shcherbakov

  1. Objective of the Review: To analyze the state-of-the art for eradicating pylori, approaches to treating concomitant imbalance in intestinal flora, and therapies for mixed gastrointestinal (GI) infections.
  2. Key Points: Frequent antibiotic use for various GI infections leads to the emergence of antibiotic-resistant strains of microorganisms. Dealing with this resistance problem goes hand in hand with the necessity to treat disorders affecting different parts of the GI tract. This paper demonstrates the possibility of using nitrofurans to treat different combinations of GI infections. It also describes the author's own experience. The author provides the rationale for including these agents in eradication regimens for pylori infection and treatment plans for Giardia infection, imbalance in the composition of the intestinal microbiota — including cases where it was caused by antibacterial agents — and mixed infections.
  3. Conclusion: Adding Nifuratel to eradication regimens is helpful in successfully overcoming antibiotic resistance of pylori strains and in achieving high eradication rates. This also allows for effective treatment of Giardia infection and imbalances in intestinal microbiota caused by various problems, including previous antibacterial therapy.

Keywords: Helicobacter pylori, Helicobacter pylori infection, mixed infections, Nifuratel.

Using Probiotics For Conditions Associated With Diarrhea

  1. S. Vyalov

Objectives of the Review: To describe clinically significant etiological factors of diarrhea associated with various conditions and disorders; to summarize the results of research studies that evaluated the use of probiotics in patients suffering from diarrhea; and to discuss how to choose treatment for diarrhea and how to use probiotics to prevent and treat this condition.

Key Points: A review of recently published scientific papers suggests that when choosing probiotics, preference should be given to preparations containing combinations of specialized strains that focus on specific needs, i.e. targeted probiotics.

Conclusion: Rioflora, a specialized probiotic complex, has been proven effective in treating gastrointestinal disorders associated with microbial imbalances and the use of antibacterial agents.

Keywords: diarrhea, probiotics.

Clinical Case: Intestinal Obstruction as Consequence of Capsule Endoscopy in Patient with Crohn's Disease

  1. A. Danilov, A. O. Atroschenko, S. M. Tchudnyh, P. L. Shcherbakov, I. E. Khatkov

Purpose of the Paper: To demonstrate the potential and safety of capsule endoscopy, even in cases where it is associated with intestinal obstruction, and to inform doctors about possible complications of Crohn's disease.

Key Points: The authors describe a rare clinical case where they detected a narrowing of the small bowel and its exact location during capsule endoscopy. Due to the course of the disease, elective surgery was impossible, and bowel obstruction that developed some time later called for urgent surgical intervention.

Conclusion: Capsule endoscopy is a highly informative and safe technology to examine the gastrointestinal mucosa. However, in some situations (certain conditions or specific features of the course of the disease), the capsule's passage through the intestinal tract can be difficult or impossible. When inflammation progresses, the capsule, if it can't pass the narrowing, is a diagnostic marker for a surgeon and helps the doctor to choose the quickest access to the affected site.

Keywords: video capsule endoscopy, Crohn's disease, intestinal stricture, acute intestinal obstruction, intestinal resection, foreign body.

Bowel Preparation for Instrumental Examinations: Comparing Different Regimens

  1. L. Shcherbakov, V. A. Rogozina, O. V. Kirillov, A. I. Parfenov, E. A. Albulova, A. B. Ershkova

Study Objective: To compare different regimens used to prepare the colon for colonoscopy, based on physicians' objective judgments and patients' opinions.

Study Design: This was a partially double-blind study.

Materials and Methods: The authors followed up 180 patients (mean age 47.8). The following preparation regimens were used: a polyethylene glycol (PEG)-based laxative; enemas and a solution of magnesium sulfate used to cleanse the bowel; and a solution based on sodium phosphate used as a laxative agent. The effectiveness of the preparation was assessed by patients' subjective judgments and by endoscopy specialists’ opinions, based on the Chicago Bowel Preparation Scale.

Results: With PEG- and sodium-phosphate based solutions, the effectiveness of preparation did not differ significantly. With magnesium sulfate, used in combination with enemas, bowel cleansing was much poorer, and there was more residual fluid. None of these methods of bowel preparation was associated with significant changes in patients' clinical characteristics or laboratory data.

Conclusion: Strict adherence to a low-residue diet is essential for adequate bowel preparation. Endoscopy specialists and patients believe that Fleet Phospho-Soda Solution was the best of all studied agents.

Keywords: colonoscopy, polyethylene glycol, Macrogol, Fleet Phospho-Soda Solution.

Robot-Assisted Technique for Pancreaticoduodenectomy

  1. G. Krieger, S. V. Berelavichus, D. S. Gorin, A. R. Kaldarov, N. A. Karelskaya, E. A. Akhtanin

Study Objective: To compare the use of robot-assisted and conventional techniques for pancreaticoduodenectomy (PDE).

Study Design: This was a retrospective study.

Materials and Methods: We examined the results of a pylorus-preserving PDE in a group of 14 patients with tumors of the pancreatic head and periampullary region. In 7 patients, the procedure was done using a robot-assisted technique, and 7 patients were operated on using the conventional method.

Study Results: The procedure's duration was 460.71 ± 119.77 min and 288.57 ± 62.20 min for a robot-assisted and conventional PDE, respectively. In procedures performed using the robot-assisted and conventional techniques, the volume of blood loss was 414.28 ± 285.36 mL and 400 ± 163.30 mL, respectively. All postoperative complications following robot-assisted procedures were considered grade I events, and all complications following conventional procedures were considered grade II events as assessed by the Clavien-Dindo classification. In the group of robot-assisted PDE, none of the patients had a pancreatic fistula (ISGPF, 2005); while in the group of conventional PDE, there was one such case. In addition, patients in the group of robot-assisted PDE had shorter periods of abdominal drainage and narcotic pain therapy; moreover, not all patients required narcotics. Histology showed that the number of removed lymph nodes was higher in the group of robot-assisted PDE.

Conclusion: Precise dissection of the major vessels and lymph nodes as well as accurate formation of anastomoses are the obvious advantages of the robot-assisted technique. Robot-assisted PDE complies with all requirements for cancer-curative surgeries.

Keywords: pancreaticoduodenectomy, robot-assisted surgery.

Hepatic Alveolar Echinococcosis: Potential of Ultrasound Examination at Different Stages of Combined Surgical Treatment

  1. A. Stepanova, D. A. Ionkin, O. I. Ashivkina, O. I. Zhavoronkova, A. V. Chzhao, V. A. Vishnevsky

Study Objective: To determine the potentials of a combined surgical approach in treating hepatic alveolar echinococcosis and to identify the role of ultrasound examinations at different treatment stages.

Study Design: This was a retrospective study.

Materials and Methods: The authors evaluated the examination findings and treatment outcomes of 17 patients, aged 19 to 76, with significantly advanced hepatic alveolar echinococcosis, who were followed-up between 2012 and 2015. All patients had ultrasound examinations at different stages during the treatment. A combination surgical approach with cryodestruction was used in all cases. In the postoperative period, patients received anthelmintic agents.

Study Results: The following procedures were performed: liver resection with cryodestruction (n = 14), only cryodestruction (n = 1), and a two-stage procedure with cryodestruction in two patients with separate lesions in both hepatic lobes. Various complications developed in the short- and long-term postoperative periods. However, during the follow-up period that lasted from 2 months to 3.5 years, patients received anthelmintic agents and the disease did not progress.

Conclusion: A combination of liver resection and cryodestruction of the residual parasite tissue can be considered a curative treatment method for hepatic alveolar echinococcosis. Ultrasound is an effective diagnostic technique, especially when major vessels are involved. It allows a specialist to obtain more detailed intraoperative information, to monitor cryodestruction, and to assess the evolution of postoperative complications.

Keywords: alveolar echinococcosis, ultrasound examination, cryodestruction.

Virtual Simulation During Laparoscopic Adrenalectomy: ‘Expensive Toy’ or Effective Support?

  1. A. Kurganov, S. I. Emelyanov, D. Yu. Bogdanov, N. L. Matveev

Study Objective: To compare the outcomes of laparoscopic adrenalectomy performed with and without 3D-virtual simulation and intraoperative navigation.

Study Design: This was a retrospective, comparative study.

Materials and Methods: We analyzed the outcomes of 123 laparoscopic adrenalectomies. In 24 (19.5%) cases, surgery was done using 3D-virtual simulation and intraoperative navigation (study group). In 99 (80.5%) cases, laparoscopic adrenalectomy was performed using standard techniques (control group).

Study Results: The rates of complications were 4.2% in the study group and 8.1% in the control group (p > 0.05). The mean time to ambulation was 6.5 ± 2.4 and 7.9 ± 4.1 h (p < 0.05), respectively, and the need for pain therapy remained for a mean period of 18.7 ± 7.0 and 22.3 ± 8.9 h (p < 0.05), respectively.

Conclusion: Laparoscopic adrenalectomy with 3D-virtual simulation and intraoperative navigation is associated with better surgical outcomes. However, the procedure's benefits can only be accessed in large specialized surgical centers.

Keywords: laparoscopic adrenalectomy, 3D-virtual simulation, intraoperative navigation, adrenal gland neoplasms.

Internal Combined Biliary and Pancreatic Fistulas: Clinical Case

  1. A. Soloviev, D. N. Panchenkov, N. V. Mokshina, T. A. Briginevich

Purpose of the Paper: To analyze literature data and to describe the authors' own experience with a female patient who was diagnosed with acute calculous cholecystitis, complicated by a biliary-enteric fistula, and an internal pancreaticogastric fistula (complication of prior acute pancreatitis and a postnecrotic cyst).

Key Points: In a patient with acute calculous cholecystitis, preoperative examination revealed some fistulas; this finding called for urgent changes in the treatment strategy. Ultrasound of internal organs did not provide enough data to clarify the diagnosis pre-surgery. A contrastenhanced computed tomography was the most informative procedure — it showed internal gastric and intestinal fistulas.

Conclusion: In patients with calculous cholecystitis, chronic pancreatitis and pancreatic cysts, the preoperative detection of combined fistulas between the common bile duct, pancreas, and duodenum is a challenging problem. Diagnostic techniques available at clinical facilities help change approaches to surgical treatment and achieve optimal results.

Keywords: acute calculous cholecystitis, acute pancreatitis, cholecystectomy, biliary-enteric fistula.

Toothpick Perforation of Colon: Clinical Case Report and Literature Review

  1. S. Fomin, V. V. Naletov, D. R. Zinatulin, V. G. Mikhailov, D. V. Nikolaev

Objective of the Paper: To describe a rare clinical case of colonic perforation by a foreign body (toothpick).

Key Points: In surgical practice, gastrointestinal perforations by foreign bodies are an extremely rare manifestation of acute abdomen. Most often they are observed in patients who have hernias or Meckel's diverticulum. This clinical case demonstrates the possible challenges when a foreign body is found in the ascending colon. It also provides a rationale for using minimally invasive diagnostic and therapeutic technologies in patients with this condition.

Keywords: acute abdomen, colonic perforation, toothpick.

Short-Term Results of Modified the Appleby Procedure: Authors’ Experience and Literature Data

  1. I. Egorov, R. V. Petrov, N. S. Starostina, Y. A. Zhurina, N. M. Nikolaev, M. V. Grigoryevsky

Study Objective: To assess the safety of the modified Appleby procedure (a distal pancreatectomy with en bloc resection of the coeliac axis [DP-CAR]), and to discuss unresolved issues related to its use.

Study Design: This was a retrospective study.

Materials and Methods: The authors performed a retrospective and prospective review of 19 medical charts of patients who had undergone DP-CAR for ductal adenocarcinoma in the body of the pancreas (n = 17), neuroendocrine cancer (n = 1), or lymphoma (n = 1). Pre-surgery computed tomography and intraoperative ultrasound Doppler scanning were used to establish the diagnosis and to decide whether the procedure could be done without arterial reconstruction. The study also included an analysis of publications that described more than two cases of this procedure.

Study Results: According to the authors’ data, postoperative complications developed in 11 (58%) patients and were successfully treated in 9 cases. In all patients, postoperative pain was successfully managed. There were no cases of ischemic complications. All patients but one received chemotherapy. Two out of 19 (10.5%) patients died in the short-term postoperative period. The causes of death included aortic dissection on day 10 and fungal sepsis on day 44 after surgery. The literature review included 29 papers that described 333 procedures. In 41.1% of these cases, patients had procedure-related complications. According to these literature data, the 90-day postoperative mortality was about 4%.

Conclusion: For some patients with locally advanced and borderline resectable tumors arising from the body of the pancreas, DP-CAR is an effective and safe procedure.

Keywords: distal pancreatectomy, resection of the coeliac axis, Appleby procedure, pancreatic body cancer.

Abdominal Aortic Aneurysm: Using Radiopaque Diagnostic Agents Before and After Surgery — Literature Analysis

  1. V. Deryabin, A. V. Chupin, R. V. Kolosov, V. N. Lesnyak, A. S. Titovich

Objective of the Review: To discuss the value of computed tomography (CT) in planning for endovascular aneurysm repair and assessing surgery's short- and long-term outcomes.

Key Points: CT is characterized by perfect spatial resolution, high penetration power and widespread availability. It is recognized as the gold standard for both estimating the possibility of endovascular aneurysm repair and for assessing the outcomes of endoscopic and open surgeries. CT's disadvantages include the use of ionizing radiation and contrast agents and its higher costs compared to ultrasound.

Conclusion: Computed tomography is highly effective in detecting endoleaks after endovascular aneurysm repair. However, there is no consensus about an optimal CT protocol because this technique is associated with ionizing radiation and requires the use of potentially nephrotoxic contrast agents.

Keywords: endovascular aneurysm repair, endoleak, computed tomography.

Endovascular Interventions as Part of Combination Treatment for Budd-Chiari Syndrome

  1. N. Kotiv, S. A. Alentyev, I. I. Dzidzava, S. J. Ivanusa, P. N. Zubarev, A. L. Muzharovsky

Study Objective: To assess the potential of endovascular interventions as part of a combination treatment for patients with Budd-Chiari syndrome.

Study Design: This was a retrospective clinical study.

Materials and Methods: In 15 patients with Budd-Chiari syndrome, the supra-hepatic block in the portal venous system was caused by stenosis or occlusion of the hepatic veins (HV), and in another 23 patients, who had liver cirrhosis or congenital abnormalities, this block resulted from stenosis or occlusion of the intrahepatic portion of the inferior vena cava (IVC). Endovascular interventions included balloon dilatation of stenotic lesions in HV (n = 19), stent placement in the hepatic vein trunk (n = 2), transjugular intrahepatic portosystemic stent shunting (TIPSS) (n = 2), balloon dilatation of stenotic lesions in the intrahepatic portion of IVC (n = 22), stent placement in IVC (n = 10), and chronic embolization of the splenic artery (n = 5).

Study Results: No severe complications or deaths were reported. As early as 7 days after treatment, the quality of a patient's life was higher than before the intervention. When balloon angioplasty was performed for isolated stenosis of the HV ostia, it resulted in prolonged decompression of the hepatic venous system. Stenting and TIPSS were effective for extended stenosis of HV. In patients with stenosis or occlusion of the intrahepatic portion of IVC, stent placement in the affected segment was the most effective and least traumatic method of treating portal and vena caval hypertension.

Conclusion: Combining endovascular methods and other minimally invasive and conventional bypass techniques is highly effective in treating portal and vena caval hypertension in patients with Budd-Chiari syndrome.

Keywords: Budd-Chiari syndrome, occlusion of hepatic veins, stenosis of inferior vena cava, balloon dilatation, stenting, portacaval shunting.

Ultrasonic Diagnosis of Complications After Lip Augmentation

  1. A. Stepanova, N. N. Vetsheva, N. O. Sultanova, I. E. Timina, D. S. Lombrozo

Study Objective: To assess the potentials of ultrasonic (US) examination in detecting complications after lip augmentation with injectable fillers.

Study Design: This was a comparative, prospective study.

Materials and Methods: The authors examined and treated 101 patients, aged 24 to 65, who had developed complications after lip augmentation with injectable fillers. The following injectable fillers were used: biopolymer gel (Group I; n = 70, 69.3%), polyacrylamide gel (Group II; n = 8, 7.9%), and hyaluronic acid preparations (Group III; n = 23, 22.8%). All women underwent US examination pre-surgery and then either in the post-operative period or as part of their periodic follow-up.

Study Results: Group I: The soft lip tissue was replaced by diffuse hyperechoic masses showing signal attenuation toward image periphery. Duplex scanning did not reveal blood flow in these masses. Group II: Well-defined anechoic and hypoechoic rounded or polycyclic avascular forms (geleomas) of varying size and pattern were detected in lip soft tissue; the surrounding tissue appeared very indurated and had a higher echogenicity. Duplex scanning revealed significantly reduced or no blood flow in the lips. Group III: The US pattern depended on the time passed from filler injection. The lip vascular pattern was preserved.

Conclusion: US examination of the lip soft tissue and the nasolabial fold following augmentation procedures helps assess the patient's condition, detect procedural complications and correct or completely cure them. If necessary, ultrasound can be used to monitor the state of the soft tissue.

Keywords: lips and nasolabial folds, soft tissue augmentation, complications, ultrasound diagnosis.

Diagnostic MSCT and Planning for Surgical Treatment for Patients with Orbital-Wall Injuries and Post-Traumatic Deformities

  1. V. Davydov, D. A. Lezhnev, D. I. Kostenko

Study Objective: To evaluate how multi-slice spiral computed tomography (MSCT) can help in diagnosing orbital-wall injuries and posttraumatic deformities and in making decisions about surgical treatment in this patient population.

Study Design: This was a case control study.

Materials and Methods: The study was based on an analysis of clinical data and MSCT findings from 112 patients with orbital-wall injuries and posttraumatic deformities. These data were obtained during examinations performed as part of pre-operative planning and post-operative follow-up.

Study Results: With the developed technique, specialists can measure damaged orbital walls and, based on these measurements, make correct decisions about surgical treatment and choose appropriate implants. This helps achieve satisfactory results in restoring the anatomy of the bony orbit.

Conclusion: Examination plans for patients with orbital-wall injuries and post-traumatic deformities should include computed tomography. MSCT helps assess the severity of orbital-wall deformities; its results are key factors in determining the choice of optimal treatment techniques.

Keywords: injury, orbit, imaging diagnosis, multi-slice spiral computed tomography.

Doctor.Ru Cardiology Internal Medicine No. 2 (119), 2017

Seasonal and Air-Temperature Effects in Patients with Stable Ischemic Heart Disease

  1. L. Kozlovskaya, O. S. Bulkina, V. V. Lopukhova, N. A. Chernova, O. V. Ivanova, T. E. Kolmakova1, A. T. Shubina, O. A. Fomicheva, E. V. Sorokin, K. A. Talitsky, I. V. Starostin, V. V. Buza, F. F. Byazrova, E. V. Lukoshkova, V. V. Ermishkin, S. V. Emelina, K. G. Rubinshtein, Yu. A. Karpov

Study Objective: To study the effects of weather changes on the incidences of cardiovascular events and changes in some parameters of laboratory tests and instrumental investigations in patients with ischemic heart disease (IHD).

Materials and Methods: During the study, 100 IHD patients were examined in cold and warm seasons, and 23 of them were additionally examined during the heat wave in July 2014. In autumn and spring and during heat waves, all patients were contacted by phone and asked to complete a questionnaire. Forty-eight people regularly self-recorded repeated single-channel resting electrocardiograms (ECG), using an AATOS device, and sent these recording to the server.

Study Results: Compared to the warm season, the cold season was marked by the following changes: hematocrit levels increased by 0.2% (р < 0.005), plateletcrit levels elevated by 0.01% (р = 0.01), and hemoglobin levels increased by 0.8 g/L (p = 0.006). Compared to the warm season, in the cold season, angina patients tended to have higher levels of C-reactive protein (р = 0.06) and elevated red blood cell distribution width (р = 0.03), and showed a statistically significant increase in the degree of ischemic ST depression (3.0 ± 1.0 mm vs. 1.0 ± 0.5 mm), as was shown by Holter ECG monitoring. The study showed a correlation between fibrinogen concentrations and average monthly temperatures (r = 0.7; p < 0.05). During heat waves, plasma creatinine and sodium levels were higher, and plasma potassium and chloride levels were lower than during warm weather. Average daily temperatures lower than –2 °C and higher than +21 °C were associated with a decrease in the parameters of heart-rate variability: pNN50 (by 85.9% and 79.1%, respectively; p < 0.0001 for both cases), RMSSD (by 25.5%, p = 0.005 and 19.2%, respectively; p < 0,02), and HF (by 40,8%, p < 0.005 and 30.5%, p < 0.004; respectively). During heat periods, LF power and LF/HF values were significantly lower (up to 90.9 ms2; p = 0.04 and 1.48; p = 0.02, respectively).

Conclusion: For IHD patients, summers, without extreme heat, is the most favorable season.

Keywords: ischemic heart disease, heart-rate variability, fibrinogen, heat wave, cold season, weather factors.

Effectiveness and Safety of Statins in Cardiac Surgery Patients

  1. L. Barbarash, O. V. Maleva, O. A. Trubnikova

Objective of the Review: To provide the latest results of clinical observations on the perioperative effects of statins in patients who are undergoing coronary artery bypass grafting (CABG).

Key Points: This review shows that statins are highly effective and safe agents that can be used in most patients before CABG. They have also been proven to be effective in reducing 1-year mortality in patients who have undergone CABG. Statins are generally well tolerated by cardiac surgery patients. Some statins show similar safety profiles. The most significant side effects include elevation of hepatic transaminases and rhabdomyolysis. One of statins’ main adverse effects is myopathy. In patients receiving statin monotherapy, myopathy develops in 1 out of 1,000 subjects, and is dose-dependent.

Conclusion: One hypothesis states that the effects of statin treatment can be comparable to those of myocardial revascularization. A recent study showed that in patients with ischemic heart disease, high doses of atorvastatin are as effective as angioplasty combined with conservative therapy. Now, however, the main effort should be to explain, both to doctors and patients, the necessity of long-term statin treatment and to encourage patients to adhere to this therapy.

Keywords: coronary artery bypass grafting, statins, perioperative period.

Post-Myocardial Infarction Patients with Chronic Obstructive Pulmonary Disease: Can We Change Prognosis?

  1. L. Barbarash, O. M. Polikutina, E. D. Bazdyrev

Objective of the Review: To discuss the epidemiology and diagnosis of comorbid ST-segment elevation myocardial infarction and chronic obstructive pulmonary disease (COPD).

Key Points: This review summarizes information about the short- and long-term post-myocardial infarction period in patients with COPD, describes current treatment approaches, and provides a rationale for using cardioselective β-adrenoblockers.

Conclusion: Patients with comorbid cardiovascular and bronchopulmonary disorders, especially those who have had a coronary event, require close monitoring for possible complications and adequate evidence-based medication.

Keywords: ST-segment elevation myocardial infarction, chronic obstructive pulmonary disease, comorbid disorders, β-adrenoblockers, Bisoprolol.

Pathophysiological Approach to Treating Ischemic Heart Disease Accompanied by Renal Dysfunction

  1. V. Zykov

Objective of the Review: To provide information that could help doctors make more grounded and optimal treatment decisions for patients with ischemic heart disease (IHD) accompanied by renal dysfunction.

Key Points: This review includes information about the positive and negative effects of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, a renin inhibitor, β-adrenoblockers, aldosterone antagonists, calcium channel blockers, diuretics, statins, and proprotein convertase subtilisin/kexin type 9 inhibitors, and the changes in the effects of these agents in patients with renal dysfunction. The authors also summarize the specific features of anemia and special approaches to treating this disorder in IHD patients with renal dysfunction. Another part of the review focuses on the prevention of contrast-induced nephropathy in this patient population.

Conclusion: Since the underlying mechanism of IHD is complicated, management of this condition requires a combination approach that uses the information about the changes in the effects of medicinal products in patients with renal dysfunction.

Keywords: ischemic heart disease, renal dysfunction, pathogenesis-based treatment.

Pre-Hospital Mortality in Patients with Ischemic Heart Disease Who Developed Acute Coronary Syndromes

  1. V. Kirillov

Study Objective: To analyze data over a 5-year period about pre-hospital deaths of outpatients, who were receiving emergency medical care, with respect to the type of death, underlying disorder, time of death, and its cause.

Study Design: This was a retrospective analysis.

Materials and Methods: A sample survey was conducted to study 266 pre-hospital deaths: 123 sudden coronary deaths (SCD), 74 sudden deaths not related to acute manifestations of ischemic heart disease (IHD), and 69 expected deaths.

Study Results: Of all sudden deaths, 62.4% of cases were SCD, and 37.6% of cases were sudden non-coronary deaths. Of the 123 cases of SCD, the main cause of death was acute myocardial infarction in 44 (35.8%) patients and acute coronary insufficiency in 45 (36.6%) patients. Thus, acute coronary events occurred in 72.4% of cases. Acute cardiovascular failure developed in 34 (27.6%) patients who died from SCD. Seventeen of them died of incessant angina associated with complex rhythm disorders. The other 17 patients died of terminal complications of chronic IHD such as cardiac asthma, pulmonary edema, thromboembolism and cerebral hemorrhage, and acute aneurysm of the heart.

Conclusion: In patients with IHD, sudden coronary death was the most frequent (46.2%) form of death in the pre-hospital settings. In 78.9% of cases, it was caused by fatal ventricular fibrillation.

Keywords: emergency medical care, acute coronary syndrome, sudden coronary death, life-threatening arrhythmias.

Excessive Epicardial Fat Accumulation as Cardiovascular Risk Factor: What Can Medications Do?

  1. A. Chumakova, N. G. Veselovskaya

Study Objective: To investigate the possibility of reducing excessive visceral (epicardial) fat accumulation in patients receiving telmisartan as an antihypertensive agent.

Materials and Methods: This study included 44 women, aged 40 to 55, who suffered from hypertension and general obesity. They had a body mass index ≥ 25 kg/m2 but ˂ 35 kg/m2 and epicardial fat thickness (EFT) ≥ 7 mm. These participants were divided into 2 groups. In Group I, patients received telmisartan (4080 mg/day, given as monotherapy or in combination with amlodipine) as an antihypertensive treatment. In Group II, patients received antihypertensive drugs other than sartans. The study parameters included anthropometric variables, levels of adipokines and pro-inflammatory cytokines, and blood pressure (BP) at baseline and at months 1 and 6 of treatment.

Study Results: The study showed that telmisartan 4080 mg, given as monotherapy or in combination with amlodipine, not only helped achieve the target BP levels in most patients, and significantly reduced body weight (on average by 1,51 kg per month), waist circumference, and EFT. At the end of month 6 of treatment, statistically significant changes in all study parameters were still evident. In Group II, a quick and significant reduction in body weight (by up to 5.39 kg) was observed by the end of month 1. Subsequently, the efficacy of treatment declined and body weight increased, while EFT did not significantly change during the observation period.

Conclusion: Because of its specific properties (potent activation of peroxisome proliferator-activated receptors γ, reduction in insulin resistance, and enhanced lipolysis), telmisartan not only facilitates the achievement of target BP, but also helps reduce the degree of general and visceral obesity as assessed by EFT.

Keywords: excessive epicardial fat accumulation, visceral obesity, telmisartan.

Anticoagulants: What Do Anesthesiologists and Intensivists Think?

  1. N. Pasechnik

Objective of the Review: To discuss anesthesiologists' and intensivists' opinions about the potential of anticoagulants.

Key Points: Anesthesiologists and intensivists often see patients who are receiving anticoagulants as treatment for their concomitant conditions. Also, they frequently prescribe these agents as a preventive or therapeutic treatment in life-threatening situations. With the introduction of new oral anticoagulants (NOAC) into the domestic pharmaceutical market, specialists now have a wide option in treating thrombotic complications. This review provides a detailed list of indications for NOAC and gives protocols for switching to these agents when they are being considered as alternative anticoagulants. It also summarizes management strategies for surgery patients who are receiving NOAC.

Conclusion: In surgery patients, NOAC are a reliable alternative to parental anticoagulants for treating venous thromboembolic complications.

Keywords: new oral anticoagulants, venous thromboembolic complications.

Ventilator-Associated Pneumonia: Review of Case-History Data of Patients Who Died of Myocardial Infarction or Cerebrovascular Accidents

  1. V. Odintsova, A. G. Malyavin, O. V. Zairatiants

Study Objective: To evaluate the incidence of nosocomial ventilator-associated pneumonia (VAP) in patients who died of myocardial infarction or cerebrovascular accidents.

Materials and Methods: We reviewed archive data of 140 autopsy reports and case histories of patients who died of cardiovascular accidents. Of these 140 patients, mechanical ventilation (MV) was used in 83 (59.3%) people. Depending on the risk of nosocomial VAP, these patients were divided into two groups: 32 (22.9%) patients who had been on ventilator support for less than 3 days, and 51 (36.4%) patients who had been on MV for 3 days or longer.

Study Results: Of the 83 patients on MV, 57 (68.7%) developed pneumonia. Nosocomial VAP developed significantly more often in patients who had been on MV for 3 days or longer. In this group of patients, the probability of nosocomial VAP was 4.473-fold higher (95% confidence interval: 1.815–11.024) than in those who were not put on MV or had been on MV for less than 3 days.

Conclusion: This study confirmed that nosocomial VAP is a common condition in patients with cardiovascular accidents. It is related to the length of mechanical support. Creation of treatment and management guidelines for this patient population would improve their survival and prognosis.

Keywords: nosocomial pneumonia, mechanical ventilation.

Two Disseminated Disorders in Female Patient: Clinical Case

  1. M. Kuklina, V. V. Romanov, E. I. Shmelyov

This article describes the unique case of a 57-year female patient who developed disseminated lung tuberculosis followed by sarcoidosis of the lungs and intrathoracic lymph nodes. Taking into consideration the similar morphological changes seen in these disorders and the consequential difficulties in making a differential diagnosis, the authors give a detailed description of how diagnostic samples were collected and interpreted. They also outline and justify all treatment regimens and modalities that were used to treat this patient and helped her achieve a good clinical and radiologic outcome.

Keywords: tuberculosis, sarcoidosis, disseminated disorders.

Drug-Induced Liver Injury: Still Challenging Issue

  1. O. Bueverov

Objective of the Review: To summarize key information about the epidemiology, classification, diagnosis, and treatment of drug-induced liver injury (DILI).

Key Points: According to various references, the prevalence of DILI ranges from 13.9 to 19.1 cases per 100,000 inhabitants. The following are considered key risk factors: female gender, old age, mainly hepatic metabolism of drugs, genetic characteristics of the enzymes involved in metabolism, polypharmacy, and underlying liver diseases. The most frequent histological types of drug-induced liver injury include hepatocellular, cholestatic, and mixed patterns. In most cases, DILI resolve spontaneously when the culprit drug is withdrawn. However, when a patient requires drugs with a high potential for hepatotoxicity, medications that exhibit antioxidant and anti-cholestatic properties, such as S-adenosylmethionine, should be administered as a preventive treatment.

Conclusion: DILI is a common condition that must be included in the differential diagnosis of any liver disorder.

Keywords: drug-induced liver injury, epidemiology, classification, diagnosis, treatment.

Diabetic Neuropathy in Patients with Comorbidity

  1. L. Vertkin, N. O. Khovasova, A. V. Naumov, G. Yu. Knorring

Objective of the Review: To address the issue of diabetic neuropathy, one of the most common complications of diabetes mellitus (DM). Diabetes mellitus is a severe socially significant chronic disease that considerably reduces quality of life and increases overall vascular risk.

Key Points: DM complications, with diabetic neuropathy (DN) being the most common, often affect work productivity and lead to early disability and death. Diabetic neuropathy is not a separate condition but a serious complication of diabetes mellitus and concomitant metabolic disorders. This highlights the importance of timely detecting neuropathy and starting appropriate treatment. Management strategy’s mandatory components include blood glucose monitoring, improving tissue trophic processes, and restoring damaged nerve fibers (remyelination). Main agents that produce these effects include neurotropic B vitamins and medications used to correct metabolic disorders.

Conclusion: Timely diagnosis and treatment can improve the quality of life of patients with diabetic polyneuropathy. Treatment includes therapeutic modalities that influence neural trophic signals and different steps of metabolism and contribute to remyelination of damaged nerve fibers.

Keywords: polyneuropathy, diabetic neuropathy, remyelination.

Oxidative Metabolism of Lipoproteins in Patients with Multifocal Atherosclerosis

  1. A. Berns, E. A. Shmidt, O. V. Chuvichkina, T. A. Khomyakova, O. A. Nagirnyak, O. L. Barbarash

Study Objective: To investigate the relationship between lipoproteins’ oxidative-metabolism parameters and the severity and location of atherosclerotic lesions in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

Study Design: This was a prospective, cohort, registry study.

Materials and Methods: The registry included 415 consecutively hospitalized patients with NSTE-ACS; 266 of them underwent an examination of their three vascular beds. All patients were divided into the following groups: Group I patients did not have atherosclerotic lesions; Group II patients had atherosclerotic lesions only in their coronary arteries; and Groups III and IV patients had stenotic lesions in their two and three vascular beds, respectively. The authors measured peripheral-blood levels of oxidized low density lipoproteins (LDL) and antibodies

(Ab) against oxidized LDL.

Study Results: The highest levels of oxidized LDL were seen in patients with multifocal atherosclerosis (MFA). In patients who had lesions only in their coronary arteries and those who had lesions affecting two vascular beds, the levels of oxidized LDL were more than twice as low as in Group IV patients. The lowest levels of oxidized LDL were observed in patients who had no signs of atherosclerosis. No significant differences were seen between the groups in their levels of Ab against oxidized LDL. However, patients who did not have atherosclerosis tended to have higher levels of these antibodies.

Conclusion: The prevalence of MFA in this NSTE-ACS patient population was 44%. Patients who have atherosclerotic lesions affecting three vascular beds have higher concentrations of oxidized LDL than NSTE-ACS patients who have only coronary atherosclerotic lesions or those who have no signs of atherosclerosis.

Keywords: non-ST-segment elevation acute coronary syndrome, oxidized low density lipoproteins, antibodies against lipoproteins.

Doctor.Ru Gynecology Endocrinology No. 3 (120), 2017

Proliferation and Apoptosis' Role in Adenomyosis Accompanied by Chronic Pelvic Pain

  1. R. Orazov, A. O. Dukhin, E. N. Nosenko

Study Objective: To assess proliferation and apoptosis in the ectopic and eutopic endometrium in the uterine body in women with adenomyosis accompanied by chronic pelvic pain (CPP).

Study Design: This was a prospective morphological analysis.

Materials and Methods: The study included a morphological examination of gross specimens of uterine bodies obtained during hysterectomies in 60 patients with grade II–III diffuse adenomyosis accompanied by severe CPP. Cell proliferation and apoptosis, using Ki-67 and р53 monoclonal antibodies, respectively, were investigated to evaluate cell kinetics. The sensitivity to estrogens was assessed using monoclonal antibodies to estrogen receptors.

Study Results: The study showed many proliferating cells (12.8 ± 2.7%; 95% CI: 6.5-20.7%) in the surface epithelium and their immaturity.

The latter was reflected by a high nuclear/cytoplasmic ratio and the absence of a well-developed apical pole. Glands took 28.4 ± 3.2% (95% CI: 23.4-33.2%) of the endometrial volume. Some of them appeared as tortuous structures that were focally dilated, particularly in the deep layers of the endometrium. The highest number of mitoses was seen in the necks and fundi of the uterine glands, where the number of Ki-67 immune positive cells was 17.3 ± 2.8% and 23.5 ± 3.6%, respectively. In the bodies of the uterine glands, the proportion of proliferating cells did not exceed 6%. Proliferating cells were also present in the stroma of the eutopic endometrium; however, the number of multiplying cells here was lower than in the endometrial epithelial structures (8.8 ± 4.2%; 95% CI: 5.3-11.8%).

Conclusion: Chronic pelvic pain caused by adenomyosis is accompanied by disturbed epithelial-mesenchymal interactions, which reflects impaired morphogenesis in the uterine glands. This is accompanied by enhanced proliferation of epithelial cells and increased sensitivity of epithelial and stromal cells to estrogens.

Keywords: adenomyosis, chronic pelvic pain, eutopic endometrium, ectopic endometrium, morphology, Ki-67, p53, estrogen receptors.

Cervical Neoplasia: New Approaches to Pathogenesis-Oriented Treatment

  1. N. Bebneva, E. L. Muizhnek, S. I. Rogovskaya, V. I. Kiselev, L. A. Ashrafyan, M. B. Khamoshina

Objective of the Review: To provide insights into the molecular mechanisms that underlie the occurrence of cervical neoplastic lesions and provide a rationale for new approaches to pathogenesis-based treatment of these lesions.

Key Points: Key mechanisms that cause pathogenic changes in the cervix include: human papilloma virus (HPV) infection of the cervix, enhanced proliferation in infected tissues, reduced apoptosis, disturbed balance of estrogen metabolites, and abnormal epigenetic modifications. Today, a number of natural compounds — such as indole-3-carbinol and epigallocatechin-3-gallate — have been confirmed to have a wide spectrum of antitumor activity and inhibit hyperplastic changes in epithelial tissues.

Conclusion: Understanding the pathogenesis of precancerous lesions helps practitioners find a reasonable approach to managing HPVassociated disorders. Using natural agents that have antitumor properties, we can target the molecular mechanisms underlying pathogenic changes in cervical tissues.

Keywords: dysplasia, cervical intraepithelial neoplasia, human papilloma virus, proliferation, apoptosis, indole-3-carbinol, epigallocatechin-3-gallate, abnormal epigenetic modifications.

Hormonal Contraception and Risks for Breast Disorders

  1. N. Leonidova, V. N. Mikova

Study Objective: To evaluate breast-examination data obtained from women taking an oral contraceptive containing estradiol valerate and dienogest.

Study Design: This was a prospective, cohort study.

Materials and Methods: As part of the study, we examined 39 female patients, aged 18 to 45, who had various manifestations of benign breast disease (BBD). This included clinical examination and X-ray scanning. For all patients, an oral contraceptive containing estradiol valerate and dienogest was recommended as a birth-control method.

Breast examination was done before hormonal contraception was started, and after 3 and 6 months of follow-up. This examination included an assessment of the skin covering the breasts, breast consistency, shape, symmetry, homogeneity, tenderness, and a check for mass lesions.

Study Results: After 3 months of using this oral contraceptive containing estradiol valerate and dienogest, the intensity of mastodynia significantly decreased. This effect was particularly evident in women who had severe breast pain at baseline. After 6 months of follow-up, most women (61.5%) reported no mastodynia. A follow-up ultrasound examination revealed positive changes: the breast ductal network had become less prominent, the milk ducts had normal diameter, and no content was present in the ducts. Resolution of cysts was another finding: most cysts measuring up to 10 mm had completely resolved.

Conclusion: This study showed that a combination of estradiol valerate and dienogest can be considered an acceptable birth-control method for women with breast disorders, particularly fibrocystic breast changes and mastodynia.

Keywords: benign breast disease, mastodynia, oral contraceptives, estradiol valerate, dienogest.

Oxidative Stress as One of The Causes of Benign Mammary Dysplasias and Potentials for Its Management

  1. V. Pokul, N. A. Chugunova

Study Objective: to access changes of the lipid peroxidation (LPO) parameters and nitric oxide derivatives, the intensity of chemiluminescence (CL) in patients with benign mammary dysplasias (BMD) who receive course treatment with Mastopol.

Study Design: prospective observational study.

Materials and methods. Serum concentrations of aryl hydroperoxides (AHP), malondialdehyde (MDA), the intensity of luminol-dependent CL, levels of peroxynitrite, nitroso glutathione and 3-nitrotyrosine, activities of superoxide dismutase (SOD) and catalase (CAT) were measured in patients with BMD and healthy subjects. The study patients were stratified according to the BMD variant: group I (n = 137) included patients with diffuse form of BMD, group II (n = 105) included patients with nodal growth form of BMD. The control group included healthy women (n = 126). The patients were enrolled according to the results of ultrasound and clinical examination. The healthy women (with no breast changes) had reference values of LPO parameters. The mean age was 36.29 ± 0.33 years (σ = 6.3). BMD was treated with homeopathic medicine Mastopol, 1 sublingual tablet 3 times a day. The duration of treatment was 8 weeks. The study parameters were estimated before treatment and in 4 weeks after the end of treatment.

Study Results. The study findings show a significant increase of LPO product concentrations and a decrease in antioxidant activity in the study cohort, which were more profound in patients with the nodal growth form. Course treatment with Mastopol led to significant decrease in LPO parameters and levels of nitric oxide metabolites, to regress in the light sum of CL in plasma, to a significant increase in CAT and SOD activity.

  1. Course treatment with Mastopol was associated with significant decrease in LPO parameters, the concentration of free radicals, with an increase in CAT and SOD activity. These findings offer wider prospects for use of herbal products with biologically active phenol and alkaloid compounds with antioxidant effect in the complex pathogenetic treatment of BMD.

Keywords: oxidative stress, lipid peroxidation, antioxidant treatment, Mastopol, benign mammary dysplasias.

Menopausal Hormone Therapy for Abnormal Uterine Bleeding in Perimenopause

  1. V. Kuznetsova, I. V. Tikhonovskaya

Study Objective: To evaluate the efficacy and safety of using a medication, which is intended for menopausal hormone therapy (MHT) and contains 2 mg of estradiol valerate and 0.15 mg of levonorgestrel, to treat symptoms of menopausal syndrome in women with abnormal uterine bleeding (AUB) in perimenopause.

Study Design: This was an open-label, prospective, non-controlled study.

Materials and Methods: The study included 53 women who complained of vasomotor symptoms and AUB during the menopause transition. In all women, the severity of menopausal symptoms was assessed using the Kupperman Index (KI) (Uvarova modification). All participants underwent a pelvic ultrasound examination and hysteroscopy with dilation and curettage, followed by a morphological investigation of endometrial samples. A medication containing 2 mg of estradiol valerate and 0.15 mg of levonorgestrel was administered as an MHT drug.

Study Results: The effects of hormone therapy, assessed after 6 months of treatment, showed that all menopausal complaints had become less significant, and the mean score of the modified KI had gone down, from 22.2 ± 2.53 to 9.5 ± 0.59 (p < 0.001). The study treatment was also associated with an improvement in the state of the endometrium. Endometrial polyps and diffuse endometrial hyperplasia were detected in 34 patients (64.2%) before treatment, and in 3 patients (5.7%) after treatment (р < 0.01). Before treatment, the most common morphological diagnosis was simple hyperplasia of the endometrium; after treatment, morphology confirmed normal proliferation in most women. Simple hyperplasia recurred in one woman who had had the same morphological diagnosis before treatment. This was also observed in two patients who had had complex hyperplasia of the endometrium before treatment.

Conclusion: The MHT medication, containing a combination of levonorgestrel and estradiol valerate, is effective in treating menopausal symptoms, provides good control of the menstrual cycle, and is safe for the endometrium.

Keywords: menopause transition, vasomotor symptoms, abnormal uterine bleeding, endometrial hyperplasia, menopausal hormone therapy.

Managing Symptoms of Vaginal Atrophy during Treatment with Gonadotropin-Releasing Hormone Agonists

  1. A. Oboskalova, I. V. Lavrentieva, O. V. Prokhorova, A. V. Vorontsova

Study Objective: To improve the outcome of treatment with gonadotropin-releasing hormone agonists (GnRH-a) and to improve patients' quality of life by using local therapies to relieve symptoms of vaginal atrophy.

Study Design: This was an open-label, prospective, non-controlled study.

  1. Materials and Methods: In 30 women who had symptoms of vaginal atrophy and used GnRH-a, complaints were assessed, using a visual analogue scale; a vaginal health index (VHI) score was calculated; vaginal pH was measured; and the number of Lactobacillus casei var. Rhamnosus Döderlein was determined before, during, and after treatment with (a medication containing 0.2 mg of estriol, 2.0 mg of progesterone, and 341 mg of L. casei Rhamnosus Döderlein (Trioginal).
  2. Study Results: After 8 weeks of treatment, all women saw the number of Lactobacillus casei Rhamnosus Döderlein return to normal, vaginal pH drop from 6.02 ± 0.1 to 4.10 ± 0.1 (p < 0.05), and VHI score increase from 2.1 ± 0.2 to 4.3 ± 0.1 (p < 0.05). Clinical parameters and subjective assessments showed that vaginal dryness, burning, and itching had disappeared, and the intensity of dyspareunia had significantly lessened. No adverse events were reported during this study.

Conclusion: Trioginal helps eliminate the clinical manifestations of vaginal atrophy and improve the quality of life of women using GnRH-a.

Keywords: gonadotropin-releasing hormone agonists, vaginal atrophy, estriol, Trioginal.

Current Insights into Problem of Adhesions

  1. O. Dubrovina

Objective of the Review: To outline the most controversial aspects of the pathogenesis of pelvic adhesions and methods of their prevention and treatment.

Key Points: Postoperative adhesions are a serious complication in patients undergoing abdominal surgery. Most strategies to prevent adhesions in operative gynecology focus on improving surgical techniques that use anti-adhesion barriers. The latter can be either pharmacological anti-adhesion agents or physical barriers. Surgical techniques that minimize peritoneal trauma help reduce but not prevent postoperative adhesions. Various topical and systemic medications can reduce the intensity of local inflammatory response, inhibit the coagulation cascade, and facilitate fibrinolysis. Few randomized clinical studies have confirmed the efficacy of most of these agents in preventing the formation of intraperitoneal adhesions after gynecological surgeries.

Conclusion: The search for effective anti-adhesion barriers is far from being completed; thus future studies in this field are considered justified. However, some publications have confirmed the efficacy of hyaluronic acid preparations.

Keywords: adhesions, pathogenesis, barriers, gynecology, laparoscopy, prevention.

Antibacterial Treatment for Chlamydia Infection During Pregnancy

  1. N. Kravchenko, V. A. Okhlopkov, M. V. Naboka

Study Objective: To assess the therapeutic efficacy and safety of Josamycin in treating Chlamydia infection in pregnant women.

Study Design: This was a retrospective analysis.

Materials and Methods: The study included a review of 198 individual pregnancy assessment forms, labor and delivery charts, and newborn medical-history forms. Out of the 198 female patients in the study, 100 had a confirmed Chlamydia infection of the urogenital tract (main group). Ninety-eight women who did not have this infection were included in the control group. Women who complained of a specific genital discharge and clinical manifestations of infection, were given a battery of examinations for sexually transmitted infections. These included a check of female genital discharge for Chlamydia trachomatis and Mycoplasma genitalium (PCR), aerobic and facultative anaerobic microorganisms (culture tests) and antibiotic susceptibility. In addition, endocervical swabs were collected for microbiology culture testing. Laboratory diagnosis of Chlamydia infection was based on direct detection of the pathogen. In all women, vaginal, cervical (from within the cervical canal), and urethral swabs were collected to detect Chlamydia, using a polymerase chain reaction (PCR). If PCR was positive, venous-blood samples were checked for IgM, IgA, and IgG anti-Chlamydia antibodies. All pregnant women who had Chlamydia infection were seen by a specialist in skin and venereal diseases. In the main group, participants were given Josamycin 500 mg orally 3 times a day for 10–14 days. The study also included an assessment of the course of pregnancy; labor, delivery, and postpartum complications; and neonatal outcomes. Statistical analyses included a group comparison, using the chi-square test (χ2) for qualitative parameters, and an analysis of variance, in particular a calculation of means.

Study Results: The study treatment completely eradicated the symptoms present on the first visit: discharge disappeared after 5 to 8 days, and itching and burning after 3 to 5 days. The evaluation of follow-up swab samples showed that treatment was 100% effective, i.e. no samples of biological material contained the deoxyribonucleic acid of Chlamydia trachomatis. In the main group, the follow-up bacterioscopy and culture examinations showed positive changes (less marked leukocyte response and no growth of facultative opportunistic anaerobs). The rates of complications of pregnancy, labor, and delivery, and those in the postpartum period did not significantly differ between the groups. No newborn had a Chlamydia infection. This suggests that Josamycin is a safe and effective therapeutic option.

Conclusion: This study showed that using Josamycin in pregnancy was safe and had a high therapeutic efficacy.

Keywords: Chlamydia infection, pregnancy, Josamycin.

Prenatal Diagnosis of Chromosomal Abnormalities: Clinical- and Cost-Effectiveness

  1. S. Emeliaynenko, N. V. Vetrova, S. V. Masyuk, A. A. Isaev, I. D. Evtushenko

Study Objective: To assess the suitability of adding a noninvasive prenatal test (NIPT) to the existing screening algorithm used to detect fetal chromosomal abnormalities (CA) in pregnant women. The assessment was made using data obtained in Tomsk Region.

Materials and Methods: The study’s first stage evaluated the detection rate for CA in Tomsk Region. The second stage included calculations of total direct healthcare costs for Tomsk Region in detecting CA, based on fees for these tests performed as part of the country's mandatory medical insurance plans; and indirect healthcare costs related to the birth of babies with karyotype abnormalities. The third stage was a costeffectiveness analysis, which helped choose a diagnostic algorithm based on the minimal healthcare costs of one detected case of CA. This analysis included the following alternative scenarios: 1) identifying patients at high risk of CA. This included ultrasound (US) examinations and blood-chemistry workups, followed by invasive prenatal diagnostic (IPD) tests that detect CA; and 2) two model algorithms identifying patients at high risk of CA. This included US examinations and blood-chemistry workups, followed by NIPT or a combination of NIPT and IPD tests to confirm CA.

Study Results: The study model with NIPT helps detect 94.59% of CA in patients at high risk of aneuploidy who have been selected by using the conventional screening model. Using NIPT will help minimize the cost of one detected case of CA.

Conclusion: In the Russian healthcare environment, adding NIPT to a screening algorithm for women at high risk of fetal CA, which was modelled in this study, and combining it with invasive diagnostic tests seems to be a preferable strategy. This strategy allows for a higher CA-detection rate and lower rates of false-positive results. It also helps reduce the rate of invasive procedures and thus prevents unjustified termination of pregnancies. In the long run, this will allow the regional government to save money.

Keywords: noninvasive prenatal test, screening for chromosomal abnormalities, economic analysis.

Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Glycosylated Hemoglobin Levels and Body Weight in Patients with Type 2 Diabetes Mellitus

  1. M. Mkrtumyan, T. N. Markova, N. K. Mishchenko

Objective of the Review: To provide the results of clinical studies that evaluated the effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors on glycosylated haemoglobin HbA1c levels and body weight in patients with type 2 diabetes mellitus (T2DM).

Key Points: These studies showed that in patients with T2DM glucose reabsorption in proximal tubules is increased; this is one of mechanisms that leads to hyperglycemia. A new group of glucose-lowering agents — SGLT2 inhibitors — block reabsorption of glucose in proximal convoluted tubules and thus induce glycosuria in diabetic patients. A unique characteristic of SGLT2 inhibitors is their insulin-independent mode of action. These drugs induce a maximum of 70–90 g of daily urinary glucose excretion and an associated reduction in HbA1c levels (on average by 0.8–0.9%) and in body weight, mostly by decreasing the amount of visceral fat.

Conclusion: SGLT2 inhibitors not only significantly reduce hyperglycemia but also decrease body weight, mostly through the loss of visceral fat; the latter effect is especially important for T2DM patients.

Keywords: type 2 diabetes mellitus, sodium-glucose linked transporter 2 inhibitors, glycosuria, body-weight reduction.

Polycystic Ovary Syndrome: Multidisciplinary Issue

  1. E. Grodnitskaya, N. A. Ilina, T. V. Dovzhenko, O. A. Latyshkevich, M. A. Kurtser, G. A. Melnichenko

Study Objective: 1) To evaluate the mental and sexual health, psychological well-being, and quality of life of patients with polycystic ovary syndrome (PCOS); and 2) to identify potential associations between the parameters of psychological well-being, specific clinical manifestations (phenotypes) of PCOS, and treatment compliance.

Study Design: This was an overall-population descriptive, analytical study.

Materials and Methods: The study included 96 women of reproductive age who had PCOS, as defined by the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine criteria. All these women underwent a comprehensive assessment of their psychopathological symptoms, using the MINI-International Neuropsychiatric Interview 6.0 (MINI-6.0), Hospital Anxiety and Depression Scale (HADS), Symptom Checklist 90 ― Revised (SCL-90-R), WHO (Five) Well-Being Index (WHO-5), and Female Sexual Formula (quantification scale).

Study Results: At the time of their participation in the study (mean age, 26.9 ± 4.1), 41.7% of women with PCOS had signs of anxiety and/or depressive disorder (as assessed by MINI-6.0 and HADS), and 34.5% showed a clinically significant reduction in quality of life (as assessed by WHO-5). Signs of sexual disturbances were found in 69.2% of sexually active patients. Signs of psychosocial disturbances were present in 71.6% of participants (as assessed by SCL-90-R). This study showed correlations between the following parameters: the intensity of anxiety and depressive symptoms, the level of psychological distress, quality of life, sexual disturbances, certain social factors, and a clinical picture of PCOS. Patients had been referred to between 2 and 12 gynecologists; and the median follow-up was 8 years. They changed doctors every 2 years. The authors identified specific features of referral pathways in patients with different fenotypes of PCOS.

Conclusion: Promising measures include developing modern guidelines, based on a comprehensive approach to diagnosing and treating PCOS, and providing women with PCOS with educational programs and seminars held at gynecologists' offices with the participation of doctors specialized in other fields.

Keywords: polycystic ovary syndrome, depression, anxiety, quality of life, psychological discomfort, sexual disturbances.

Doctor.Ru Neurology Psychiatry No. 4 (121), 2017

Prevalence of Parkinson's Disease in Moscow Region

  1. R. Bogdanov, S. V. Kotov

Study Objective: To evaluate the prevalence of Parkinson's disease (PD) in Moscow Region (MR), a large Russian region; and to assess the relationship between PD prevalence and the environmental situation.

Study Design: This was an evaluation of PD prevalence in MR based on the number of patients’ repeated visits to healthcare facilities.

Materials and Methods: The authors examined 1,702 patients with extrapyramidal disorders, who had been referred by neurologists working in MR. Of these, 1,489 people had parkinsonism, including 1,168 people who had PD. A correlation analysis was carried out to study PD's expected prevalence and certain parameters that characterize the environmental situation in MR. These environmental data were provided by the Federal State Budget-Funded Institution Central Office of Hydrometeorology and Environmental Monitoring.

Study Results: The average expected PD prevalence in MR was 93.3 ± 44.6 cases per 100,000 people; cases were unevenly distributed among different districts. The study showed a correlation between PD prevalence and the following: the total amount of air pollutants, amounts of carbon oxide and nitrogen oxides, and the standard index that reflects which pollutants and by how much they exceed the maximum permissible content. Additionally, a direct correlation was found between PD prevalence and release of pesticides into the soil in rural areas in 1995 and 1996.

Conclusion: PD prevalence is unevenly distributed in MR. Further, more detailed studies are required to find a direct correlation between PD prevalence and environmental parameters in MR.

Keywords: Parkinson's disease, prevalence of Parkinson's disease, risk factors.

Treating Asthenia and Cognitive Impairment in Patients with Chronic Cerebral Ischemia: Idebenone's Potential

  1. N. Bogolepova, E. A. Kovalenko

Objective of the Review: To describe the uses of Idebenone to treat asthenia and cognitive impairment in patients with chronic cerebral ischemia (CCI).

Key Points: Early symptoms of CCI include asthenia that is frequently associated with anxiety and depressive disorders. Cognitive disorders are another frequent clinical manifestation. Ischemic/hypoxic cell injury is related to perturbations in mitochondrial function and decreased mitochondrial respiratory chain enzymatic activities. One possible cause of such abnormalities might be a deficiency of coenzyme Q10. Idebenone, a synthetic derivative of coenzyme Q10, is a potent antioxidant. It also normalizes the brain metabolism of serotonin, dopamine and acetylcholine. Idebenone is effective in treating asthenia and cognitive and emotional disorders associated with CCI. It is well tolerated and does not interact with other medications.

Conclusion: Using Idebenone as part of a pathogenesis-oriented therapy to treat asthenia and cognitive disorders in patients with cerebrovascular diseases can be considered well-proven and beneficial.

Keywords: chronic cerebral ischemia, asthenia, cognitive impairment, Idebenone.

Cognitive Impairment and Metabolic Syndrome

  1. V. Zakharov, N. V. Vakhnina, D. O. Gromova

Objective of the Review: To analyze the role of metabolic syndrome in the development of cognitive impairment (CI).

Key Points: Cognitive impairment is a common neurological symptom, especially in old and senile patients. Risk factors for CI include such common vascular and metabolic disorders as hypertension, hyperlipidemia, abdominal obesity, and impaired glucose metabolism. A combination of these disorders, known as metabolic syndrome, is associated with an extremely high risk of CI. Metabolic syndrome increases the likelihood of both vascular and degenerative brain pathologies associated with CI.

In patients with CI and metabolic syndrome, treatment should be targeted at the main causes of metabolic syndrome (such as insulin resistance and excess weight) and at pathogenic mechanisms underlying secondary cerebral injury. Effective therapeutic options for patients with non-dementia CI caused by vascular or neurodegenerative disorders include neurometabolic stimulants and antioxidants, such as choline alfoscerate and ethylmethylhydroxypyridine succinate.

Conclusion: Metabolic syndrome is associated with an increased risk of cognitive impairment caused by either vascular or neurodegenerative cerebral disorders.

Keywords: cognitive impairment, metabolic syndrome, insulin resistance, endothelial dysfunction.

Markers of Endothelial Dysfunction in Ischemic Stroke, Depending on Its Pathogenic Subtypes

  1. Yu. Ryabchenko, A. M. Dolgov, E. N. Denisov, N. V. Aptikeeva, N. G. Gumanova

Study Objective: To investigate specific patterns of changes in markers of endothelial dysfunction in ischemic stroke (IS) and different stroke subtypes.

Study Design: This was a case-control study.

Materials and Methods: We examined 110 male and female patients with IS and divided them into several subgroups, depending on the cause of stroke: atherosclerosis (thrombosis), cardioembolism, and lacune. On days 1–2 and days 12–15, serum levels of nitric oxide were assessed by measuring the total concentration of its stable metabolites (NO2 and NO3); plasma endothelin-1 (ET-1) levels were determined by an immunosorbent assay. At the same time points, neurological assessments were done using the National Institutes of Health Stroke Scale (NIHSS) and the Scandinavian Stroke Scale (SSS). The study results were processed using BioStat 2009 software.

Study Results: The least severe neurological deficit was associated with a lacunar stroke (SSS score 50.9 ± 1.3 and NIHSS score 4.1 ± 0.3); such a deficit was more evident in strokes caused by atherosclerosis (thrombosis) (SSS score 42.6 ± 1.6 and NIHSS score 6.7 ± 0.6). The biggest deficit was seen in cardioembolic strokes (SSS score 32.7 ± 3.4 and NIHSS score 12.1 ± 1.8). In patients who had a stroke caused by atherosclerosis (thrombosis), cardioembolism, and lacune, the ET-1 levels were 2.1 ± 0.7 fmol/L, 1.0 ± 0.3 fmol/L, and 0.5 ± 0.1 fmol/L, respectively. The levels of NO2 and NO3 decreased by 54.2% in patients with a cardioembolic stroke, by 25.7% in those who had atherosclerosis (thrombosis) as the stroke cause, and by 8.0% in those with a lacunar stroke.

Conclusion: The most significant changes were seen when IS was caused by atherosclerosis (thrombosis) or cardioembolism. This may suggest that these changes play a certain role in the pathogenesis of atherosclerosis (thrombosis) and cardioembolic events.

Keywords: ischemic stroke, nitric oxide, endothelin-1, endothelial dysfunction.

Functional Motor Recovery After Stroke: Evidence-Based Approach

  1. P. Yastrebtseva, A. V. Kochetkov, S. V. Nikolaeva

Objective of the Review: To outline current approaches to restoring lower-limb motor function after stroke. This was done using the example of a Scottish national clinical guideline on managing stroke patients.

Key Points: Recommendations on improving gait, balance, and mobility, based on a sufficient body of evidence, include: ankle foot orthoses; repetitive task training; muscle strength training; functional electrical simulation for drop-foot; treadmill training to increase gait speed; and electromechanical assisted gait training to restore the ability to walk. The guideline highlights the importance of an individualized approach and a safe increase in the intensity of therapy.

Conclusion: Medical rehabilitation of stroke patients with motor impairment includes tailored combinations of different methods that take into account the severity of motor deficit and the tolerability of rehabilitation interventions.

Keywords: functional motor recovery, stroke, rehabilitation, orthoses, kinesitherapy, occupational therapy, biofeedback, programmed electrical muscle stimulation.

Current Approaches to Treating and Rehabilitating Patients with Vascular Cognitive Impairment

  1. S. Preobrazhenskaya, A. A. Naumenko, N. V. Trofimova

Objective of the Review: To describe modern approaches to treating and rehabilitating patients with vascular cognitive impairment (VCI).

Key Points: Vascular cognitive impairment refers to cognitive changes of varying degrees caused by cerebrovascular disorders. This impairment is the result of damage to large areas of the brain, including zones involved in cognitive functioning. The prevalence of VCI is extremely high. When not correctly diagnosed or left untreated, it may exacerbate and lead to dementia. VCI is partially reversible. Pathogenesis-oriented treatment includes detection and treatment of cardiovascular disorders and correction of vascular risk factors. Basic symptomatic treatment for dementia includes acetylcholinesterase inhibitors and NMDA-receptor antagonists. In treating mild and moderate VCI, key measures include the identification, treatment, and prevention of conditions that cause the underlying disease; cognitive trainings; and the use of NMDA-receptor antagonists.

Conclusion: The high risk of disability in patients with untreated VCI and the high prevalence of this condition highlight the great importance of timely diagnosis and the correct treatment of VCI.

Keywords: vascular cognitive impairment, vascular dementia, acetylcholinesterase inhibitors, NMDA-receptor antagonists, cognitive-motor training.

Head Injuries: Using Neuropeptide-Containing Medication Cellex in Acute and Recovery Phases

  1. V. Saiko, L. S. Andrushko

Purpose of the Paper: To assess the efficacy and safety of Cellex, a Russian neuropeptide-containing medication, when it is used during the acute and recovery phases of brain injuries.

Key Points: Today, neuropeptide-containing medications have found their rightful place in pathogenesis-oriented treatment of head injuries. They help to contain secondary brain damage by enhancing autophagy and inhibiting the expression of proapoptotic factors. These effects contribute to the restoration of the blood-brain barrier integrity, remyelination, and active synaptogenesis and neoangiogenesis. Cellex, a medication containing neuropeptides, provides both primary and secondary neuroprotection. The efficacy of Cellex was assessed using the following parameters: neurological examination findings and electroencephalography, computed tomography, and magnetic resonance imaging data. In addition, scores were used from the Mini-Mental State Examination, the Hospital Anxiety and Depression Scale, the Sheehan Anxiety Scale, the Hamilton Depression Scale, and the Vein Vegetative Dysfunction Scale.

Conclusion: When used during the acute and recovery phases of brain injuries, Cellex was proven to be an effective and well-tolerated treatment.

Keywords: Cellex, brain injury, neuropeptides, apoptosis, autophagy.

Long-Term Evaluation of Mental Health in Chernobyl Liquidators

  1. N. Krasnov, V. V. Kryukov, I. N. Emelianova, I. A. Ryzhova, E. F. Samedova, A. M. Zakharov

Purpose of the Paper: To summarize the results of an open-label, prospective study of the mental health and the authors' experience in treating liquidators of the 1986 Chernobyl disaster.

Key Points: The study cohort included 663 liquidators, who had undergone multiple repeated examinations and treatment at the clinical unit of the Moscow Research Institute of Psychiatry between 1989 and 2016. Polymorphic symptoms tended to combine into psychoorganic syndrome. An assessment of psychopathological symptoms, a neuropsychological examination, and data obtained from instrumental examinations (single photon emission computed tomography, rheoencephalography, Doppler ultrasound, and magnetic resonance imaging) suggested that patients' diseases could be linked to early cerebrovascular impairment. The key therapeutic modalities included repeated courses of treatment with cerebroprotective and vasoactive agents. In recent years, cognitive training has become a mandatory component of the treatment plan.

Conclusion: Cerebroprotective agents that also have somatotropic (particularly vasoactive) properties help reduce, to a certain degree, asthenic, psychovegetative, and dysthymic manifestations, and partially correct cognitive impairment. Overall benefits of biological therapy, administered in combination with psychosocial interventions, contribute to the compensation of the residual cognitive impairment, which is still present as a manifestation of psychoorganic syndrome. Repeated sessions of cognitive training show very promising results.

Keywords: disaster at the Chernobyl Nuclear Power Plant, cohort of liquidators, psychoorganic syndrome, cerebrovascular pathology, long-term follow-up and treatment.

Stigmatization of Patients with HIV by Medical Professionals

  1. G. Neznanov, N. B. Khalezova, O. V. Koltsova, E. V. Selyutina, S. A. Pogodina, O. A.-Kh. Rida

Study Objective: To investigate changes in the personal attitudes of medical professionals who work in healthcare facilities of various orientations regarding their tolerance of and stigma toward people living with HIV (PLHIV).

Study Design: This was a descriptive one-off study that involved completing a questionnaire.

Materials and Methods: As part of the study, high- and middle-level medical staff working in St. Petersburg healthcare facilities completed a questionnaire and underwent psychological testing. The study was conducted at the Center for Preventing and Combatting AIDS and Infectious Diseases (n = 97), two multidisciplinary healthcare facilities (n = 109), and two mental hospitals (n = 53). A semi-structured questionnaire was developed for the purposes of this survey. Individual psychological attitudes to socially significant motivations and needs were identified, using a method developed by O. F. Potemkina; career interests were assessed, using the Holland Occupational Themes.

Study Results: Compared to their colleagues from multidisciplinary and mental facilities, specialists who constantly work with PLHIV less often make moral judgements about their patients' behavior (8.3% vs. 27.5% and 24.7%, respectively) and less often empathize with patients (17.5% vs. 40.4% and 30.4%). Also, in their professional practice, they more often demonstrate a reasonable approach to HIV issues (56.7% vs. 15.5% and 15.2%).

Conclusion: The evolution of attitudes demonstrated by medical professionals towards PLHIV involves their decision not to make moral

judgements about their patients' behavior, to show empathy toward patients, and to develop a reasonable approach to medical care. Enlarging special knowledge in HIV medicine should be coupled with the development of skills to counsel PLHIV, including skills to make psychological interventions.

Keywords: AIDS Center, HIV in a multidisciplinary clinical facility, HIV in psychiatry, stigmatization, tolerance, psychological defenses.

Wavelet Analysis of Electroencephalogram Recorded During Expectation of Threatening Information in Patients with Recurrent Depression

  1. V. Mnatsakanyan, M. G. Sharaev, V. V. Kryukov, O. S. Antipova, V. N. Krasnov

Study Objective: In patients with recurrent depression (hereafter "patients"), to investigate their specific neurophysiological characteristics associated with their unconscious expectation of seeing threatening visual information compared to those characteristics associated with their expectation of neutral visual stimuli.

Materials and Methods: The study included 30 patients who were examined before they started medication therapy and 30 healthy volunteers. A multichannel electroencephalogram (EEG) was recorded while the participants were categorizing stimuli as images of humans or animals. Half of the images were neutral, and the rest were images considered threatening. Warning stimuli were given 2 seconds before the images were shown, and the relationship between these stimuli and the images was not explained to the participants. A wavelet analysis was done for single trials; spectral power was then compared in the participants who were expecting neutral and threatening images; these comparisons were done for two time periods (1,000–1,300 and 1,300–2,000 ms after the onset of the warning stimulus).

Study Results: Differences between responses to neutral and emotion-inducing stimuli (p < 0.01), i.e. emotional modulation (EM) of EEG rhythms, manifested themselves in two ways: 1) an increased power, in some frequency bands, and certain latency ranges when participants were expecting to see angry faces; and 2) as a decreased power when they were expecting to see images of aggressive animals compared to that registered when they were expecting neutral stimuli. Emotional modulation of EEG rhythms was found in the beta and gamma EEG bands, but was almost absent in the alpha and theta bands, except for patients who were expecting to see threatening faces (p < 0.05).

Conclusion: These differences between patients and healthy participants in EM of EEG rhythms may become promising biomarkers of depressive conditions.

Keywords: electroencephalogram, wavelets, recurrent depression, expectancy, emotions.

Cognitive Impairment in Young and Middle-Aged Patients with Chronic Kidney Disease

  1. V. Fomina, M. V. Egorova, L. D. Tchesnokova

Study Objective: To assess cognitive functioning in patients with chronic kidney disease (CKD).

Study Design: This was a prospective study.

Materials and Methods: The study included 108 young and middle-aged patients with chronic glomerulonephritis associated with stage I–III CKD and 36 age-matched subjects who did not have renal disease (control group). Cognitive impairment was assessed using the Mini-Mental State Examination (MMSE) and PF-Status software.

Study Results: The Mini-Mental State Examination showed that 3 (2.8%) patients with CKD had pre-dementia cognitive impairment; these patients were not followed up. Testing using the PF-Status showed that CKD patients had mild impairment of neurodynamics, attention, and memory. In the control group, subjects did not have any cognitive problems, as assessed by MMSE and PF Status. A correlation analysis demonstrated that neurodynamic parameters depend on a person's age, glomerular filtration rate (GFR), serum cystatin C levels, and 24-hour protein excretion. The study revealed a significant negative correlation between age and attention sharing (r = –0.50, р = 0.001). No correlation was seen between cystatin C levels and attention, and cystatin C levels and memory. Stage II–III CKD was more often accompanied by cognitive disorders than stage I CKD.

Conclusion: There is a correlation between the occurrence of cognitive impairment and a patient's age and his/her GFR, 24-hour protein excretion, and cystatin C levels.

Keywords: cognitive impairment, chronic kidney disease.

Doctor.Ru Hematology No. 5 (122), 2017

Systemic Vasculitis in Children and Adults: Classification, Differential Diagnosis, and Treatment

  1. G. Rumyantsev

Objective of the Review: To outline the key differences in the manifestations of systemic vasculitis and the approaches to treating this condition in children and in adults. This was based on the evolution of criteria for differential diagnosis of different forms of vasculitis.

Key Points: Systemic vasculitis is a heterogeneous group of rare diseases that share some morphological features of inflammation in the vascular system and various clinical manifestations of allergy, hemorrhage, and necrobiosis. The range of clinical manifestations depends on the type, size, and location of the affected vessels, the presence of thrombosis or hemorrhage, and the grade and severity of concurrent inflammatory changes in the apoptotic tissues.

The clinical and morphological criteria for the classification of vasculitis in adults, proposed by the American College of Rheumatology in 1990, helped in the collection of data about the epidemiology, differential diagnosis, and treatment of systemic vasculitis. As these criteria were not validated for the pediatric population, 15 years later the Paediatric Rheumatology European Society approved the criteria for the classification of childhood vasculitides. This was done in order to identify the most typical groups of patients and to evaluate the epidemiology of this disease in children [43]. In 2012, at the Revised International Chapel Hill Consensus Conference, vasculitis associated with anti-neutrophil cytoplasmic antibodies, immune complex small vessel vasculitis (SVV), and unclassified vasculitis, described both in children and adults, were added to this list [29].

Keywords: children, primary systemic vasculitis, epidemiology, classification, treatment.

Paroxysmal Nocturnal Hemoglobinuria in Children: Literature Review

  1. A. Novichkova, U. N. Petrova, I. I. Kalinina, A. A. Maschan

Objective of the Review: To describe the mechanisms leading to the development of paroxysmal nocturnal hemoglobinuria (PNH), its clinical manifestations, and the approaches to diagnosing and treating this illness, primarily in pediatric patients.

Key Points: Paroxysmal nocturnal hemoglobinuria is a rare clonal disorder that affects hematopoietic stem cells, and is characterized by the following triad: hemolytic anemia, thrombosis, and bone-marrow deficiency. In children and adolescents, PNH is ten times less common than in adults, and is more often presented as a subclinical disease or as a combination of bone-marrow deficiency and a stem-cell defect of a polyclonal pattern; while hemoglobinuria may be absent.

For PNH, high-sensitivity flow cytometry is the most informative and reliable diagnostic tool. Children who have bone-marrow deficiency should be screened for a PNH clone. Current treatment options include the inhibition of the terminal complement pathway (Eculizumab) and bone-marrow transplantation.

This review summarizes the results of detecting a PNH clone in children with acquired aplastic anemia who were treated at the Federal State Budget-Funded Institution Dmitry Rogachyov Federal Scientific and Clinical Center for Pediatric Hematology, Oncology and Immunology, Ministry of Health of Russia, between March 2012 and September 2015 to receive treatment.

Conclusion: In combination with current treatment approaches, timely detection of PNH helps significantly reduce the risk of complications

and improve the prognosis.

Keywords: paroxysmal nocturnal hemoglobinuria, diagnosis, treatment, children.

Role of Blood Fibrinolytic Activity in Preventing Thrombosis in Normal Pregnancy

  1. P. Momot, I. Yu. Kudinova, V. A. Elykomov, N. A. Semenova, D. A. Momot, D. E. Belozerov

Objective of the Review: To analyze current insights into the role of blood fibrinolytic activity in preventing thrombosis in the later stages of pregnancy.

Key Points: Normal pregnancy is associated with increased blood coagulation. This is related to tissue-factor activity and the production of thrombin, which is usually seen in increased plasma D-dimers levels. However, the cause of this increase in D-dimers levels in the later stages of normal pregnancy remains unknown. This review includes an analysis of changes in the levels of plasminogen and key regulators of fibrinolysis. The authors show that intravascular fibrinolytic activity near the vessel wall is inhibited before delivery, while systemic fibrinolysis (in general circulation) is activated.

Conclusion: The authors suggest that an increase in plasma D-dimers levels observed in the later stages of pregnancy could be explained by the lysis of soluble fibrin that has not yet transformed into a fibrin clot.

Keywords: normal pregnancy, thrombin production, fibrin, fibrinolysis, D-dimers.

Human Recombinant Erythropoietins for Treatment of Anemia in Pregnancy

  1. G. Demikhov, M. Aiari, E. N. Zinovyeva, E. V. Demikhova, I. M. Mirov, A. G. Rumyantsev

Objective of the Review: To describe the potentials of using human recombinant erythropoietins in pregnancy to treat anemia.

Key Points: When treating anemia in pregnant women, clinicians often have to deal with resistance to therapeutic iron replacement — the main treatment option for this clinical and hematological syndrome. This resistance is commonly related to an inadequately low production of erythropoietin, which explains the high effectiveness of human recombinant erythropoietins. Increased interest in using these drugs in obstetrical practice is explained by new data about their high effectiveness and their safety in treating anemia in pregnant women and early anemia in preterm newborns.

Conclusion: Using human recombinant erythropoietins in combination with iron products is an effective and safe treatment option for anemia in the second half of pregnancy.

Keywords: anemia in pregnancy, treatment, human recombinant erythropoietin.

Bioimpedance Analysis as Part of Pre-Surgery Examination in Pediatric Hematology: Literature Review

  1. V. Kurlykin, A. N. Konstantinova, V. A. Yakimenko, Yu. G. Ovsyannikov

Objective of the Review: To evaluate the possibility of using medical techniques based on bioimpedance measurements to assess the potential perioperative risks in patients with hematological disorders.

Key Points: Diagnostic techniques based on bioimpedance measurements are nonivasive tools that help monitor hemodynamics and also assess and optimize respiratory support in patients with acute respiratory-distress syndrome. A quantitative body-composition analysis is used in the treatment of nutritional disorders. Monitoring body-water compartments is useful in providing anesthesia and renal-replacement therapy. Bioimpedance measurements help identify patients who are at high risk of complications associated with hematopoietic stem-cell transplantation.

Conclusion: In children with hematological disorders, bioimpedance measurements, taken as part of a preoperative examination, will help significantly reduce anesthesia-related risks and increase the safety of therapeutic and diagnostic procedures.

Keywords: bioimpedance measurements, body-composition analysis, rheography, electromyography, anesthesia, infusion therapy, children.

Allogeneic Hematopoietic Stem-Cell Transplantation in Children with Hurler's Syndrome

  1. S. Borovkova, K. I. Kirgizov, E. V. Skorobogatova, L. S. Zubarovskaya, B. V. Afanasiev, A. G. Rumyantsev

Study Objective: To compare the efficacy of myeloablative conditioning (MAC) and reduced-intensity conditioning (RIC) regimens used for allogeneic hematopoietic stem-cell transplantation (allo-HSCT) in children with Hurler's syndrome.

Materials and Methods: We analyzed the outcomes of allo-HSCT in 31 patients with Hurler's syndrome (total number of procedures 33). The median age was 15 months (324 months) at the time of diagnosis and 22 months (9–42 months) at the time of allogeneic transplantation. The preparation for allo-HSCT included MAC (24 procedures in 23 children) or RIC (9 procedures in 8 children).

Study Results: Twenty-six patients are still alive; the median follow-up is about 50 months (7–140 months). The overall 4-year survival rate is 69.5 ± 0.16%, irrespective of the intensity of the preparatory regimen.

Conclusion: When used in children with Hurler's syndrome as part of preparation for allo-HSCT, full-intensity and reduced-intensity conditioning regimens show similar efficacy.

Keywords: children, mucopolysaccharidosis type I, hematopoietic stem-cell transplantation.

Bone Destruction in Multiple Myeloma: Main Independent Prognostic Factor?

  1. P. Bityukov, O. A. Rukavitsyn

Study Objective: To assess the effect of bone destruction, polyneuropathy, renal failure, and diabetes on the survival time of multiple myeloma (MM) patients.

Materials and Methods: The study included a retrospective analysis of 29 closed files of patients who had received treatment at the Federal State Public Institution N. N. Burdenko Main Clinical Military Hospital, Ministry of Defense of the Russian Federation, from 1988 until 2014. These patients had been followed up from diagnosis to death. The study population included 24 men (82.8%) and 5 women (17.2%), aged 46 to 83 (median age 66). Most of these patients (69.0%; n = 20) were old and senile.

Study Results: We studied the rate and severity of bone destruction, polyneuropathy, renal failure, and diabetes in 29 deceased MM patients. In these MM patients, bone destruction that developed during the first year of treatment was significantly more severe than it was at the onset of the disease.

Conclusion: Bone destruction can be an independent prognostic factor in an analysis of survival times in MM patients.

Keywords: multiple myeloma, complications, bone destruction, polyneuropathy, renal failure, diabetes, treatment periods, differences, correlation analysis, survival times.

ThromboPath Assay for Assessment of Hemostasis in Children with Deep Vein Thrombosis

  1. A. Zharkov, A. V. Poletaev, M. A. Gratcheva, E. A. Seregina, A. V. Pshonkin

Study Objective: To determine the sensitivity and specificity of the ThromboPath assay for detecting abnormalities in the protein C system in children with deep-vein thrombosis who are receiving treatment for malignant neoplasms.

Materials and Methods: Patients, aged 1 to 16 (n =30), were prospectively recruited in a study cohort. The study examinations included measuring protein C activity, levels of free protein S and lupus anticoagulant (dilute Russell's viper venom time and testing with a silica activator), and activated protein C resistance (APCR) and the ThromboPath assay.

Results: The sensitivity and specificity of the ThromboPath assay were 78% and 71%, respectively, and its positive predictive value and negative predictive value were 90% and 50%, respectively. The Spearman's rank correlation coefficient (Rs) was 0.47 (*Р = 0.03), 0.18 (Р = 0.42) and 0.53 (*Р = 0.01) for the correlation between the results of the ThromboPath test and protein C activity, free protein S levels, and APCR, respectively.

Conclusion: The ThromboPath assay is a sensitive and effective screening tool for finding abnormalities in the protein C system in children with deep-vein thrombosis.

Keywords: ThromboPath, thrombosis, thrombophilia, children, protein C, screening.

Extrahepatic Portal Hypertension in Paroxysmal Nocturnal Hemoglobinuria: Clinical Case

  1. V. Dezhenkova, O. F. Nikulina, N. V. Tsvetaeva, E. A. Kitsenko, E. P. Sysoeva, E. A. Lukina

Purpose of the Paper: 1) To outline the difficulties of the differential diagnosis between paroxysmal nocturnal hemoglobinuria (PNH) and a rare thrombotic complication — extrahepatic portal hypertension complicated by recurrent gastrointestinal hemorrhage, and 2) to describe the difficulties in determining optimal treatment approaches in such situations.

Key Points: PNH is a rare acquired clonal blood disorder. The main characteristics of classical PNH include chronic intravascular hemolysis and a high rate of thrombotic complications that lead to irreversible damage of vital organs. Nowadays, the diagnosis of PNH relies on flow cytometry to identify the abnormal population of cells deficient in superficial GPI-anchored proteins. The implementation of immunophenotyping of PNH clone cells into clinical practice has significantly improved the diagnosis of this condition.

Difficulties in the differential diagnosis of PNH are illustrated by a clinical case of portal vein thrombosis and extrahepatic portal hypertension complicated by recurrent gastrointestinal hemorrhage in a female patient.

Conclusion: When diagnosed at late stages, PNH is associated with severe thrombotic complications that damage vital organs or organ systems, which may become the main clinical problem and result in death.

Keywords: paroxysmal nocturnal hemoglobinuria, anemia, thrombocytopenia, portal vein thrombosis, extrahepatic portal hypertension, splenectomy.

Principles for Providing Anesthesia to Pediatric Patients with Hematological Disorders During Minimally Invasive Procedures

  1. G. Ovsyannikov, V. V. Shchukin, E. A. Spiridonova, P. A. Zharkov

Objective of the Paper: To outline the principles for providing anesthesia to pediatric patients with hematological disorders during minimally invasive procedures.

Key Points: These principles were used as a basis for anesthesia protocols for minimally invasive procedures. The protocols were implemented at the Federal State Budget-Funded Institution Dmitry Rogachyov Federal Scientific and Clinical Center for Pediatric Hematology, Oncology and Immunology Ministry of Health of Russia. This paper also includes a description of a clinical case: a pre-operative examination and the delivery of anesthesia to a child with hemorrhagic thrombocytopenia, a concurrent deficiency of dense and alpha-granules of platelets.

Conclusion: In pediatric patients with hematological disorders, minimally invasive procedures should be performed in accordance with approved protocols and regulations for anesthetic services. Management protocols currently available for this patient population should be further developed and refined.

Keywords: anesthesia services, intravenous anesthesia, hemorrhagic syndrome, inhalation anesthesia, tracheal intubation, minimally invasive procedures, thrombocytopenia.

Case of Diamond–Blackfan Anemia Accompanied by Severe Transfusional Iron Overload

  1. V. Fedorova, L. I. Papusha, G. V. Tereshchenko, A. M. Mitrofanova, M. E. Lokhmatova

Objective of the Paper: To describe a case of Diamond–Blackfan anemia (DBA) accompanied by severe transfusional iron overload, and to raise the awareness of chelation therapy in transfusion-dependent patients with DBA.

Key Points: Diamond–Blackfan anemia is a congenital bone-marrow-insufficiency syndrome characterized by birth defects and the inhibition of erythropoiesis.

Corticosteroids and RBC transfusions, followed by iron chelation, are the mainstay of therapy for DBA. Both therapies are associated with severe side effects.

This paper includes a description of a clinical case of DBA in a pediatric patient who had prolonged iron overload.

Conclusion: Management of DBA is challenging because serious treatment-related side effects are almost inevitable. The early initiation of appropriate chelation therapy is critical.

Keywords: Diamond–Blackfan anemia, iron overload, children.

Doctor.Ru Pediatrics No. 6 (123), 2017

Bronchial Obstruction in Infants: Case-Specific Approach

  1. A. Ilienkova, S. V. Smirnova, N. A. Solovieva, I. V. Cherepanova

Study Objective: To identify the most significant predictors of different types of bronchial obstruction in infants, based on a review of their medical-history data, specific clinical manifestations, and risk factors. This was done to optimize the differential diagnosis and to clarify the prognosis.

Study Design: This was a nonrandomized study of a case series.

Materials and Methods: Overall, 343 infants, aged 1 to 12 months, were examined in the study. These infants had bronchial obstruction at the time of their admission to hospital. The study methods included clinical-examination methods (physical examination, history-data collection, and an assessment for risk factors) and a statistical analysis.

Study Results: The authors identified the following three types of bronchial obstruction: bronchial obstruction of non-infectious origin, bronchial obstruction of infectious origin, and bronchial obstruction associated with bronchopulmonary dysplasia. The study showed that these groups differ in terms of the clinical picture, patients' medical-history data and risk factors. A logistic regression analysis was used to identify significant predictors of different types of bronchial obstruction that have different clinical and pathogenic features and to create models of these types.

Conclusion: Identification of significant predictors of different types of bronchial obstruction in infants will help optimize a differential diagnostic approach to assessing their prognosis and providing treatment and regular follow-up to children who had bronchial obstruction in infancy.

Keywords: bronchial obstruction, wheezing phenotypes, differential diagnosis, infants.

Asthma and Obesity: It All Starts in Childhood

  1. N. Surovenko, E. F. Glushkova, L. V. Luss, N. V. Shartanova

Objective of the Review: To describe current insights into the comorbidity of asthma and obesity.

Key Points: The World Health Organization strategy for childhood-obesity prevention includes, in particular, an assessment of the relationships between obesity in children and their concomitant disorders, including asthma. Of great interest are asthma and obesity’s common pathogenic mechanisms and the contribution of impaired lipid metabolism and immune regulation to chronic systemic inflammation and airway inflammation. With the above notions taken into account, the authors propose several methods to diagnose obesity in asthma patients and to treat asthma in comorbid patients.

Conclusion: Information about the interrelationship between obesity and asthma — two multi-factorial disorders — is controversial. Despite multiple studies in this field, there are still many unresolved problems.

Keywords: asthma, obesity.

Bronchial Obstruction Following Thyroidectomy in Adolescent Patient

  1. V. Spichak, O. F. Lukina

Purpose of the Paper: To describe the clinical case of bronchial obstruction in an adolescent, whose condition was caused by an unusual problem — intermittent extrathoracic airway obstruction due to vocal-cord paresis that followed a total thyroidectomy.

Key Points: In pediatric patients, bronchial obstruction can be caused by external (compression) or internal (inflammation, bronchoconstriction, airway blockage, or neurogenic disorders) factors. The diagnostic algorithm to identify the cause of this disorder depends on auscultation findings suggesting difficulty in inhalation or exhalation, medical history, and data obtained from conventional examinations, including pulmonary-function tests and chest X-rays.

Conclusion: In certain cases, multidisciplinary interaction of pediatric allergy specialists, pulmonologists, specialists in functional diagnostics, and otolaryngologists is required in order to identify rare causes of bronchial obstruction.

Keywords: bronchial obstruction, extrathoracic obstruction, vocal cord paresis, children.

Adsorbents and Cyto- and Mucoprotective Agents Used to Treat Acute Intestinal Infections

  1. V. Gorelov, A. A. Ploskireva

Study Objective: To analyze the effectiveness of currently used approaches that use adsorbents and cyto- and mucoprotective agents to treat acute intestinal infections (AII).

Study Design: This study consisted of a retrospective comparative analysis (stage 1) and a prospective, randomized, open-label, comparative, observational clinical study (stage 2).

Materials and Methods: At stage 1, different approaches to using adsorbents (dioctahedral smectite, polymethylsiloxane polyhydrate, colloidal silicon dioxide, lignin hydrolised, and kaolin) were compared in terms of their effectiveness in 123 pediatric patients, 6 months to 12 years of age, who had AII.

The study’s second stage included an efficacy assessment of adding gelatin tannate, a combination product, to background treatment in 50 age-matched pediatric patients with AII.

Study Results: Dioctahedral smectite showed the highest clinical effectiveness, and kaolin was clinically the least effective. In this study, a reverse linear relationship was established between the drug's absorption capacity and its effectiveness (coefficient of determination 0.96). Adding gelatin tannate reduced the median clinical effectiveness (time to recovery of 50% of patients) from 2.8 to 1.7 days and significantly reduced an integral index of clinical symptoms.

Conclusion: An optimal combination of absorption capacity and clinical effectiveness makes dioctahedral smectite one of the most recommended medications for patients with AII. Gelatin tannate, added to a combination treatment regimen for AII, reduces the duration and intensity of diarrhea and dehydration.

Keywords: acute intestinal infections, absorbents, dioctahedral smectite, cyto- and mucoprotective agents.

Experience with Targeted Therapy in Pompe Disease

  1. M. Lapteva, M. A. Skachkova, V. G. Korneev, N. F. Tarasenko, E. G. Karpova

Purpose of the Paper: To describe the authors' experience in following up a child with an orphan condition (Pompe disease).

Key Points: Pompe disease is a generalized glycogen-storage disease caused by a mutation of the lysosomal acid alpha-D-glucosidase gene. Enzyme deficiency that presents at birth (infantile form) is associated with severe manifestations and a worsening of cardiac and respiratory failure; it ultimately leads to death within the first year of life. Targeted (enzyme-replacement) therapy is the only specific treatment option. This paper describes the characteristic clinical features of this condition and specific diagnostic approaches. It also summarizes the authors' experience of using targeted therapy with recombinant acid alpha-D-glucosidase in a patient with the infantile form of Pompe disease.

Conclusion: Pompe disease is a rare genetic disorder with various clinical manifestations. Biochemical diagnostic techniques help detect this condition in its early stages. Early therapy improves treatment outcomes. Since Pompe disease affects several body systems, patients require a combination treatment and periodic follow-up.

Keywords: Pompe disease, children, glycogen-storage disease, targeted (enzyme-replacement) therapy.

Complicated Crohn's Disease in 17-Year Old Girl: Specific Treatment Aspects

  1. V. Gorelov, E. A. Yablokova, E. V. Borisova, E. Yu. Polotnyanko, A. A. Kanshina, A. P. Zinkevich

Purpose of the Paper: To demonstrate the specific clinical features of complicated Crohn's disease (CD) in a teenage girl whose course of biological treatment with infliximab was stopped.

Key Points: The incidence of inflammatory bowel disease, especially that of Crohn's disease, is increasing worldwide. In children, this disorder is more aggressive and is associated with early complications. For children, treatment options for active perianal complications include surgery, antibacterial therapy, and biological (tumor necrosis factor inhibitors) agents. This paper describes the case of a 17-year-old girl with CD — ileocolitis complicated by stenosis of the ileocecal valve and perianal fistula. After infliximab treatment (two infusions), she experienced a clinical improvement — her fistula closed. However, a premature discontinuation of this therapy led to a worsening of her intestinal symptoms and perianal complications of the underlying disease.

Conclusion: Deviations from the approved biological-therapy regimen are unacceptable as they negatively affect the clinical course of the underlying disease.

Keywords: Crohn's disease, biological therapy, infliximab.

Efficacy of Enterosorbents in Treating Giardiasis in Children

  1. I. Danilova, O. Yu. Trusova, E. I. Golovachyova, A. N. Roshchupkin, E. N. Kuznetsova, E. A. Tchernykh

Study Objective: To assess the efficacy of the enterosorbent Zhidkij ugol for kids when used as part of a combination treatment of giardiasis in children.

Study Design: This study consisted of a cross-sectional epidemiologic examination of a 10% random representative sample and a prospective, randomized, comparative part.

Materials and Methods: Overall, 64 children, aged 5 to 14, with a confirmed diagnosis of giardiasis were divided into three groups. During the run-in-treatment phase, Group I (n = 22) received Zhidkij ugol for kids; Group II (n = 22) received activated charcoal; and Group III (control group, n = 20) did not receive any enterosorbents. During the next treatment phase, all groups additionally received albendazole.

The efficacy of treatment was assessed using the results of a comprehensive clinical examination and laboratory tests performed before and after treatment.

Study Results: A full treatment course helped achieve a complete resolution of symptoms in 59.1% and 27.3% of patients in Groups I and II, respectively; in Group III, there were no changes in the disease's clinical manifestations. A 10-day course of causal therapy completely eradicated Giardia from the intestine in 100.0%, 77.3% and 75% of patients in Groups I, II, and III (control), respectively.

Conclusion: In children, a combination treatment for giardiasis shows the highest clinical effectiveness when it includes the enterosorbent Zhidkij ugol for kids.

Keywords: giardiasis, enterosorbents, children.

Using Probiotics in Pediatric Practice: Clinical Study Results

  1. A. Kharitonova, T. V. Kucherya

Study Objective: To assess the effects of Bac-Set Forte, a probiotic preparation, on gut microbiota and the clinical manifestation of diarrhea, constipation, and atopic dermatitis (AD) in children.

Study Design: This was a randomized, observational, placebo-controlled clinical study.

Materials and Methods: Children, aged 4 to 12, were randomized into 5 groups. The main groups included patients with malabsorption and diarrhea associated with antibacterial treatment and rotavirus infection (n = 30); those with constipation associated with changes in diets (n = 30); and those with AD (n = 30). Control groups included patients with functional intestinal disorders that developed after acute intestinal infections, food poisoning, cycles of antibiotics or changes in usual diets (n = 15), and those with AD (n = 15). In addition to their background treatment, patients in the main groups received Bac-Set Forte, a probiotic preparation, and patients in the control groups received placebo.

Before and after treatment, patients underwent a general clinical examination, ultrasound examination, and fecal tests, including those that detect alterations in the native gut flora.

Study Results: In all main groups, Bac-Set Forte administration was associated with statistically significant changes that reflected the normalization of digestion and the resolution of allergy-related changes and inflammation in the intestinal wall. This was confirmed by clinical and laboratory findings. However, the control groups did not show any statistically significant changes from the baseline values.

Conclusion: Probiotic Bac-Set Forte is highly effective in treating chronic diarrhea and constipation, and in inhibiting allergic and inflammatory reactions associated with food allergy.

Keywords: probiotics, children, changes in bowel habits, diarrhea, constipation, atopic dermatitis.

Perinatal Nervous-System Disorders in Pediatric Patients: Functional Outcomes and Ways to Treat Them

  1. G. Khachatryan, M. S. Maksimova, I. Yu. Ozhegova

Study Objective: To compare the efficacy of Homeostres, a homeopathic drug, and Phenibut, a conventional pharmaceutical agent, in treating neurotic disorders in children.

Study Design: This was a prospective randomized study.

Materials and Methods: Eighty-seven children with neurotic disorders were selected from a group of 168 children, aged 4 to 12, who had functional perinatal nervous-system defects. These 87 children were randomized into the Homeostres (n = 43) and Phenibut (n = 44) groups. The study methods included a clinical assessment of patients' neurological and medical conditions, brain magnetic-resonance imaging, electroencephalogram, and transcranial Doppler ultrasound of the brain vessels, complete blood count, and blood chemistry. Emotional and psychological condition was assessed by the Lüscher color test and the Children's Manifest Anxiety Scale modified by A. M. Prikhozhan (2002), with the latter being used in children aged 8 and older. Children were also seen by a pediatrician, ophthalmologist, speech therapist, and psychologist.

Study Results: In the Homeostres group, anxiety and phobias disappeared in 46.5% of children; sleep, communication skills, and emotional condition improved in 51%, 23%, and 32% of cases, respectively. In the Phenibut group, motivation and communication skills improved in 18.5% and 20.5% of children, respectively. Anxiety and phobias disappeared in 38.5%, and sleep improved in 53% of patients.

Conclusion: In children, Homeostres reduces levels of anxiety and phobias and improves motivation and sleep. It is well-tolerated and does not cause side effects.

Keywords: consequences of perinatal nervous-system disorders; functional nervous-system defects, neurotic disorders, Homeostres, Phenibut.

Ways to Improve Treatment Options for Acute Respiratory Viral Infections in Children

  1. A. Geppe, N. A. Krylova, E. N. Tyurina, E. A. Yablokova

Study Objective: To assess the clinical efficacy and safety of Oscillococcinum, a homeopathic drug, compared to symptomatic therapy in treating acute respiratory viral infections (ARVI) in children.

Study Design: This was an open-label, randomized, comparative, observational study.

Materials and Methods: Overall, 80 children, aged 1 to 14, who had ARVI, were followed up in the study. Fifty patients (main group) received Oscillococcinum, and thirty children (control group) received symptomatic therapy.

Follow-up continued for 10 days. The treatment efficacy was assessed by clinical-examination findings, the intensity of ARVI symptoms (evaluated using a 0-to-2 scale), and any side effects. Another study parameter was the number of patients who had their ARVI symptoms resolved within 48 hours after therapy started.

Study Results: After the first two days, ARVI symptoms completely had resolved in 16% of children who received Oscillococcinum, and in 6.7% of patients in the control group (OR = 2.7; 95% CI: 0.5–13.5; p < 0.001). When Oscillococcinum was given within the first hours after ARVI’s onset, the disease resolved earlier, was less severe, and patients needed antibiotics less frequently.

Conclusion: Oscillococcinum can be considered one of the most recommended effective and safe options for treating ARVI in children.

Keywords: acute respiratory viral infections, homeopathic drugs, Oscillococcinum.

Diagnostic Potential of Renal Ultrasound Elastography in Children with Metabolic Syndrome

  1. V. Borsukov, V. V. Bekezin, E. Yu. Kozlova, O. V. Peresetskaya

Study Objective: To assess the potential of using shear-wave elastography of the kidney as a noninvasive diagnostic tool for the early detection of renal disorders in obese children, with or without metabolic syndrome.

Materials and Methods: The study included 79 overweight patients, aged 11 to 17, who were divided into two groups: patients with metabolic syndrome (n = 26) and obese patients (n = 53). The control group included 16 children with normal body weight who had no urinary-tract disorders. All patients were given a renal ultrasound examination, while lying in a prone position. This procedure was done using the digital ultrasound portable system ANGIODIN-Sono/P-Ultra (NPF BIOSS, Russia) equipped with an electronic convex probe of 3 to 6 MHz.

Study Results: In children with metabolic syndrome, the stiffness of the liver parenchyma, as measured by shear-wave elastography, was 32.81 kPa in the right kidney and 29.42 kPa in the left kidney. In obese children, this parameter was 14.32 and 15.20 kPa, respectively. In the control group, the stiffness of the liver parenchyma was 7.8 kPa in the right kidney and 7.48 kPa in the left kidney.

Conclusion: Shear-wave elastography is an informative, noninvasive method of renal evaluation in children with obesity and metabolic syndrome.

Keywords: shear-wave elastography, sonoelastography, children, kidneys, metabolic syndrome.

Variability of Symptoms in McCune-Albright-Braitsev Syndrome

  1. I. Plaksina, A. V. Vitebskaya

Purpose of the Paper: To demonstrate the variability of the clinical manifestations of McCune-Albright-Braitsev syndrome in two female patients, based on data obtained from a 10-year follow-up.

Key Points: Key symptoms of McCune-Albright-Braitsev include gonadotropin-independent precocious puberty (PP) and fibrocystic bone disease that leads to bone deformity and multiple fractures. In these patients, the manifestations of McCune-Albright-Braitsev syndrome were different due to different predominant symptoms, which determined the severity of their condition and the prognosis. The first patient, who had a more significant gonadotropin-independent PP, had a lower final adult height (148 cm), and at the age of 14 she first required femoral osteosynthesis. The second patient, who had more prominent bone changes, had repeated osteosynthesis procedures and bone-replacement surgeries (first at the age of 11), but reached a higher final adult height (165.5 cm). The severity of bone changes correlated with the extent of cafe au lait macules.

Conclusion: Given the severity of this disorder and it multifactorial nature, patients with McCune-Albright-Braitsev syndrome require constant follow-up by multidisciplinary teams, including pediatricians, endocrinologists, gynecologists, orthopedists, neurologists, and other specialists.

Keywords: McCune-Albright-Braitsev syndrome, precocious puberty, fibrocystic bone disease.

Specific Features of Cytomegalovirus Infection: Literature Review

  1. S. Kochkina, E. P. Sitnikova

Objective of the Review: To provide current scientific information about the etiology, clinical manifestations, and pathological morphology for cytomegalovirus (CMV) infection, and to describe the main methods of laboratory diagnosis and treatment of this condition.

Key Points: CMV infection is a challenging issue, since it is so highly prevalent. It can be congenital or acquired. Congenital CMV infection can cause birth defects and severe illness in the neonatal period and infancy, eventually leading to death. Acquired CMV infection is observed more and more in immunecompromised patients (those who had blood transfusions or organ transplants, HIV patients, cancer patients, etc.). In such patients, CMV infection makes the underlying disease more severe and the treatment process more difficult. CMV infection often mimics other diseases.

Conclusion: A deep understanding of the role of CMV infection in the development of multi-organ dysfunction will help specialists gain new insights into many known disorders, allowing them to improve diagnosis and treatment of these conditions.

Keywords: cytomegalovirus infection, children, clinical manifestations, diagnosis.

Doctor.Ru Gynecology Endocrinology No. 7 (124), 2017

Serotonin and Cytokine Status of Patients with Chronic Pelvic Pain Associated with Peritoneal Endometriosis

  1. I. Kutsenko, R. A. Musolyants, E. I. Kravtsova, L. A. Kholina

Study Objective: To evaluate the serotonin and cytokine status of patients with peritoneal endometriosis (PE) who have chronic pelvic pain (CPP).

Study Design: This was a prospective, comparative study.

Materials and Methods: Overall, 195 patients with CPP with verified PE were examined in the study. PE was newly diagnosed in 109 (55.9%) women. 86 (44.1%) patients had recurrent CPP associated with existing PE. The patients were stratified according to the pain intensity and the disease history (newly diagnosed PE or recurrence): Group 1 (n = 53) — the pain intensity score on the visual analogue scale (VAS) was 4 to 6, newly diagnosed PE; Group 2 (n = 56) — VAS score from 7 to 10, newly diagnosed PE; Group 3 (n = 45) — VAS score from 4 to 6, recurrent PE; Group 4 (n = 41) — VAS score from 7 to 10, recurrent PE; Group 5 (n = 30) — control (apparently healthy women who come for an annual gynecology checkup). Key characteristics of the groups were comparable. Peripheral blood levels of serotonin and pro- and anti-inflammatory cytokines (IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-1 receptor antagonist — IL-1RA), and inflammatory index (II) were measured in all patients.

The reported descriptive statistics included sample average and median. The differences were considered significant when р < 0.05. Correlation analysis was based on Spearman correlation coefficients.

Study Results: Cytokine profile of the examined women indicated an inflammatory component in the pathogenesis of CPP of any intensity and in association with any PE history. The proinflammatory cytokines levels in Groups 1 and 2 were significantly higher than in the control group. Interleukin profile of groups with different pain intensity (comparison of Groups 1 and 2 and Groups 3 and 4) also varied significantly. In all groups, peripheral serotonin levels were lower than in the control group (p < 0.05). In Groups 2 and 4, serotonin levels were 110.4 ± 1.4 ng/ml and 96,1 ± 1,7 ng/ml, respectively and were significantly lower than in Groups 1 and 3 (p < 0.05). Serotonin levels in Group 4 were significantly lower than ones in Group 2 (p < 0.05).

Conclusion: The correlation analysis of the measures of the serotonin and cytokine status confirms the presence of certain trends that make the studied factors significant enough to be responsible for CPP associated with PE.

Keywords: chronic pelvic pain, peritoneal endometriosis, serotonin.

Current Approaches to Treating Endometrial Hyperplasia in Perimenopausal Patients with Chronic Endometritis

  1. V. Tkachenko, N. I. Sviridova

Study Objective: To improve treatment outcomes for perimenopausal patients who have endometrial hyperplasia (EH) associated with chronic endometritis (CE).

Study Design: This was a prospective, comparative, observational study (both EH and CE were found after a histopathological examination in patients who were admitted for hysteroscopy).

Materials and Methods: Overall, 64 patients, aged 45 to 55, with simple (n = 32) or complex EH (n = 32) with no signs of atypia associated with CE underwent a complex clinical and laboratory assessment in this study. This included a bacteriologic examination of samples taken from the cervical canal; a pelvic ultrasound examination; hysteroscopy, dilation and curettage of the uterus and cervical canal, and a morphological and immunohistochemical investigation of endometrial samples.

The control group included 10 women who came to choose a contraception method.

Patients received the following treatment: two-stage treatment for CE (the first step was administration of systemic antibiotic therapy plus Cathejell Lidocaine in utero; the second step was vaginal administration of Longidaza, a long-acting multifunctional enzyme medication) followed by hormone therapy for EH (differential prescription of gonadotropin-releasing hormone agonists or gestagens on the basis of the level of progesterone expression). The patients were followed up for 6 months.

The statistical analysis was done with Statistica 6.0 software. The significance of the differences was tested with a parametric Student’s t-test. Non-parametric Mann-Whitney test was used for unrelated populations.

Study Results: The study shows that a two-stage treatment given for CE helps restore morphological and functional reserves of the uterine endometrium. This was reflected by a statistically significant increase in endometrial expression of sex-steroid receptors (p < 0.05). After receiving hormone therapy, 95.3% of patients did not have any histopathological signs of EH, and only 4.7% of women had several foci of hyperplastic endometrium, which were histologically classified as non-atypical simple EH.

Conclusion: In patients with non-atypical simple and complex EH, an additional therapeutic step aimed at leveling the morphological and functional changes associated with CE helps improve outcomes and the effectiveness of using hormones to treat EH in perimenopause.

Keywords: endometrial hyperplasia, chronic endometritis, perimenopause.

Human Papillomavirus Vaccine and Cervical Cancer: Present-Day Ideas

  1. V. Zarochentseva, Yu. M. Belaya, L. V. Keshchian

Objective of the Review: to summarize the present-day views on cervical cancer (CC), to review objections to human papillomavirus (HPV) vaccine.

Key Points: Annually and globally, more than 500 thousands new cases of CC are diagnosed, and more than 270 thousand women die from this cause. In Russia, CC is at the 6th place (5.3%) in the general oncological morbidity pattern, and at the 3rd place (14%) in the reproductive system morbidity pattern (after breast cancer and endometrium cancer). The incidence of cervical cancer in the Russian Federation increased by 25.18% from 2003 to 2013.

HPV vaccine is a priority measure of CC prevention, along with the cytological screening. The Government of the Russian Federation approved HPV vaccine in 2007. Moscow Region (MR) was one of the first regions to perform a large-scale project of immunization against CC. It was MR where the regional program “Vaccine prevention of oncological diseases caused by human papillomavirus” was approved and has been implemented since 2008. That program covered more than 19 thousand of adolescent girls.

Conclusion: Prevention of CC is one of the global priorities of health care. A cohort as large as possible should be covered by the preventive measures aimed at lowering incidence of HPV-associated diseases.

Keywords: adolescent girls, human papillomavirus infection, cervical cancer, condylomas, vaccination, immunity.

Effect of Estradiol Valerate and Dienogest Combination on the Relapse Rate of Hormone-Sensitive Endometrial Polyps

  1. F. Mikhelson, T. E. Feoktistova, E. Yu. Lebedenko, A. A. Mikhelson, E. A. Sinelnik, M. A. Akimenko

Study Objective: was to assess effect of a combined oral contraceptive (COC) on the risk of endometrial polyps which express sex steroid receptors, after polypectomy in patients who need contraception.

Study Design: Observational study.

Materials and methods: The study enrolled 184 women who were 21–39 years old and had endometrial polyps with receptors to progesterone and estrogens that were verified by hysteroscopy and morphology. All patients needed contraception and were stratified by the chosen method after polypectomy and a separate therapeutic and diagnostic curettage. Group I included 126 women who preferred hormonal contraception. These patients took dynamic doses of COC with estradiol valerate and dienogest. Group II included 58 women who preferred barrier contraception. The observation period was 24 months, and all subjects underwent repeated hysteroscopy and targeted biopsy of endometrium after the end of this period. Significance of the differences between the groups was evaluated with χ2-test for comparison of the means and with Z-test for comparison of the rates. The difference was statistically significant at p < 0.05.

Study Results: After polypectomy and a separate therapeutic and diagnostic curettage, the polyp relapse rate was 0.8% in the group of COC with estradiol valerate and dienogest and 32.8% in the barrier contraception group (р < 0.05).

Conclusion: Administration of estradiol valerate and dienogest combination for contraception after polypectomy significantly decreases relapse rate of endometrial polyps with sex steroid receptors. This effect is thought to be mainly caused by dienogest in this combination. It seems reasonable to recommend combination of estradiol valerate and dienogest COC in dynamic dosing regimen (Qlaira) to women of reproductive age who need contraception after polypectomy. If a patient refuses to use hormonal contraception, she should be informed about the risk of relapse and related intra-uterine manipulations and about the fact that the combination product may lower this risk.

Keywords: combined oral contraceptives, endometrial polyp, expression of progesterone and estrogen receptors, contraception, prevention of polyp relapse.

Assessing Chances of Successful Implantation in In-Vitro-Fertilization

  1. A. Devyatova, K. A. Tsaturova, E. V. Vartanyan

Study Objective: To provide the rationale for the use of transvaginal ultrasound with Doppler, as a routine procedure, before embryo transfer (ET) in in-vitro-fertilization (IVF) cycles.

Study Design: This was a retrospective, comparative study.

Materials and Methods: Overall, 101 IVF cycles and ET procedures were performed in this study. In Group 1 (n = 38), blood flow was detected at all levels of uterine vessels. In Group 2 (n = 63), blood flow was absent in spiral arteries (SA). Prior to ET, all patients had transvaginal ultrasound and transvaginal ultrasound with Doppler.

Study Results: Blood flow in SA was detected in 48% of women, aged 20 to 30, and in 27,5% of women, aged 31 to 40 (p = 0.049). Blood flow in SA was absent in 34% of women with known infertility of < 5 years and in 87% of women who had been infertile for ≥ 5 years (p = 0.039). The absence of blood flow in SA was significantly more often (р < 0.05) associated with combined infertility (79.5%), unexplained infertility (77.8%), adenomyosis (72.7%), and chronic endometritis (72.7%).

When the endometrial thickness was 8-11 mm, the pregnancy rate after ET was 77.3% in Group 1 and 51.3% in Group 2. This was significantly higher than the pregnancy rate seen in women with other values of endometrial thickness. The group difference was also statistically significant. The overall pregnancy rate after ET was 63.1% in Group 1 and 39.7% in Group 2 (p = 0.045).

Conclusion: Using transvaginal ultrasound with Doppler as a method of endometrial assessment prior to ET in IVF cycles will help reduce the rate of implantation failures and significantly improve IVF outcomes.

Keywords: in-vitro fertilization, embryo transfer, in-vitro fertilization failures, endometritis, implantation window, Doppler ultrasound of uterine vessels.

Using Next-Generation Sequencing Technology for Aneuploidy Screening in Preimplantation Embryos

  1. I. Glinkina, M. A. Kurtser, E. S. Mladova, M. M. Ovchinnikova, A. Yu. Vysotsky, I. D. Trotsenko

Study Objective: To assess the effectiveness of next-generation sequencing (NGS) as a method to determine the frequency of aneuploidy in embryos created in assisted-reproductive-technology (ART) programs.

Study Design: This was an observational clinical study.

Materials and Methods: The authors studied trophectoderm cells collected from 254 embryos that were taken from 97 patients, aged 22 to 48 (mean age, 37 ± 6.3]). Preimplantation genetic screening (PGS) was performed using next-generation sequencing.

Study Results: An analysis of sequencing results detected abnormalities in 65.1% of samples, with abnormalities in chromosomes 15, 16, 21, and 22 being the most frequent. In the group of women older than 40, the incidence of trisomy was significantly higher than that in the group of women younger than 40 (p < 0.01). The highest frequency of mosaicism (37.1%) was observed in embryos taken from women younger than 35.

Conclusion: Today, NGS is the most accurate method of detecting genetic abnormalities in embryos. It can be recommended for use in assisted reproductive techniques as a means of preventing miscarriage and the birth of an affected baby.

Keywords: preimplantation genetic diagnosis, preimplantation genetic screening, in-vitro fertilization, embryos, new-generation sequencing, intracytoplasmic sperm injection.

Optimal Use of Antibacterial Agents in Obstetric Practice1

  1. O. Osipchuk, A. V. Zhilin, T. P. Pastukhova, L. G. Boronina

Objective of the Review: To summarize currently available data about an optimal use of antibacterial agents in obstetric practice.

Key Points: Perioperative antibiotic prophylaxis includes a single intravenous injection of a β-lactam antibiotic at a therapeutic dose 30 minutes before surgery (level of evidence 1A). For carriers of Streptococcus agalactiae, no treatment is recommended before delivery; antibiotic prophylaxis is given during delivery (level of evidence 2B). For asymptomatic bacteriuria and acute cystitis, the drugs of choice are oral antibacterial agents. Patients with acute pyelonephritis are given β-lactam antibiotics; the duration of treatment should be adjusted individually, and treatment must be continued for at least 7 days.

Conclusion: This review provides an evidence-based guideline on using antibacterial agents in obstetric hospitals. Treatment optimization allows for a more efficient use of drugs, helps decrease the risk of antibiotic resistance of microorganisms and contributes to reducing treatment costs.

Keywords: antibiotics in obstetrics, antibiotic resistance, antibiotic prophylaxis, group B streptococcus, Streptococcus agalactiae.

Scale for Assessing Risk of Extremely Preterm Birth

  1. S. Gondarenko, T. V. Galina, T. V. Smirnova, O. A. Kuznetsova, N. M. Markaryan, A. Obukang

Study Objective: To improve the outcomes of preterm birth (PB) by using a scale to assess the risk of extremely PB in pregnant women at risk of PB.

Study Design: This was a retrospective study.

Materials and Methods: The authors analyzed 194 pregnancy assessment forms and labor and delivery charts of women who were admitted to a the maternity department of N. E. Bauman Moscow City Clinical Hospital between week 22 and 27 (+ 6 days) of gestation with regular contractions and cervical shortening of less than 25 mm. Of them, 105 women gave birth before week 28, and 89 women gave birth after week 28.

Study Results: Risk factors of extremely PB included age of ≥ 35; body mass index of ≥ 30 kg/m2; being unmarried; a low educational level (lack of professional education); a lack of regular follow-up during pregnancy; pregestational hypertension; uterine leiomyoma; oligohydramnios; and anemia during pregnancy.

A total score of 7 or greater, as measured by the scale for assessing the risk of extremely PB, means a pregnant woman is at high risk of extremely PB. The sensitivity and specificity of this assessment was 92.4% and 89.4%, respectively, and its positive predictive value and negative predictive value were 94.6% and 85.5%, respectively.

Conclusion: Risk assessment of extremely PB should be done in all women who have cervical shortening of < 25 mm at weeks 22–28 of gestation. The proposed scale is an optimal technical tool for groups at risk. Those with a total score of 7 or greater, as measured by the scale for assessing the risk of extremely PB, should be immediately given tocolytic agents and preventive treatment for infant respiratory distress syndrome and taken to a tertiary inpatient facility.

Keywords: preterm birth, extremely preterm birth, obstetric risk, risk scale, babies with extremely low birth weight.

Specific Approaches to Delivery in Women with Sequelae of Head Injury

  1. I. Krasnopolsky, V. A. Petrukhin, K. N. Akhvlediani, A. A. Volynkin, P. N. Vlasov

Study Objective: To evaluate clinical syndromes in pregnant women with sequelae of head injury (HI) and specific approaches to choosing methods of delivery in this patient population.

Study Design: This was an open-label, prospective study with a collection of history data and clinical multidisciplinary examination.

Materials and Methods: The study included 47 pregnant women, aged 19 to 42, with a history of HI who gave birth at the State Budget-Funded Healthcare Institution of Moscow Region Moscow Regional Research Institute of Obstetrics and Gynecology between 2013 and 2015. Examination included a gynecologic and obstetric examination and consultations of other specialists who assessed the changes in clinical sequelae of HI and their intensity.

Study Results: The study demonstrated persisting functional sequelae in patients with a history of brain concussion and organic sequelae in patients with a history of brain contusion. Among women with a history of brain concussion and those with a history of brain contusion, 76.2% and 38.5% of patients, respectively, had an unassisted vaginal delivery. In other cases, assisted vaginal delivery was performed using techniques to reduce or avoid pushing efforts. In women with sequelae of HI, the mode of delivery was chosen with consideration of obstetric

indications (in 25.5% of cases), traumatic and ophthalmologic sequelae of severe HI associated with other injuries (in 10.6% of cases), and neurological disturbances (only in 6.4% of cases).

Conclusion: All women with a history of HI must undergo a multidisciplinary examination. This will help identify possible post-traumatic changes that have a significant influence on the choice of delivery method.

Keywords: sequelae of head injury, pregnant women, delivery methods.

Implementing Federal Clinical Protocol "Gestational Diabetes Mellitus" in Yaroslavl Region

  1. L. Guriev, E. M. Stepanova, O. E. Soloukhina, L. A. Sinkevich, M. A. Muradova, Yu. V. Ershova

Study Objective: To assess the results from the first year of implementation of the federal clinical protocol entitled "Gestational Diabetes Mellitus: Diagnosis, Treatment, and Postpartum Follow-Up" in Yaroslavl Region (2015 data).

Study Design: This was a retrospective analysis.

Materials and Methods: The study included an evaluation of 483 out of 545 labor and delivery charts of patients with gestational diabetes mellitus (GDM) who gave birth at the Yaroslavl Regional Perinatal Center in 2015. The control group included 14 775 patients who did not have GDM. Statistical analyses of the study data were done using Statistica 6.1. Parametric and non-parametric data were compared using the Student's t-test and the chi-square test with Yates' correction, respectively.

Study Results: This study showed that GDM was significantly more often (p < 0.05) associated with pregnancy-induced hypertension (18.6%), urinary tract infections (7.7%), and obesity (38.7%) in women, as well as shoulder dystocia (1.7%), fetal macrosomia (25.9%), and fetal hypoxia during labor and delivery (6.2%). Also, women with GDM significantly more often (p < 0.05) underwent cesarean section (28%) and had their babies transferred to an intensive care unit (8.1%). However, the frequency of intrauterine growth restriction was lower (2.7%) in this patient population. The study showed that the perinatal mortality rate in diabetic pregnancies was 1.8-fold higher than in non-diabetic pregnancies, with stillbirth being the main contributor (12.96‰ and 6.39‰ in diabetic and non-diabetic pregnancies, respectively).

The Applying modified protocol criteria to diagnose GDM led to a 2.9-fold rise in the incidence of this condition in Yaroslavl Region (from 1.2% to 3.5%). Timely identification of GDM in pregnant women helped provide them with an appropriate antenatal follow-up and refer them to the Perinatal Centre for delivery care. In 2015, 89.5% of all pregnant women with GDM gave birth at a tertiary facility.

Conclusion: An implementation of this protocol in our region helped reduce the rate of fetal macrosomia by 18.6% and led to a 2.3-fold decrease in the rate of shoulder dystocia. In addition, the early neonatal mortality (ENM) of babies with high birth weight decreased by 28.7%, and the overall ENM of term babies dropped by 13.4%.

Keywords: gestational diabetes mellitus, fetal macrosomia, perinatal mortality.

Assessment of Pleiotropic Effects of Melatonin When Used for the Treatment of Insomnia in Men with Metabolic Syndrome Who Work in Shifts

  1. S. Dzherieva, N. I. Volkova

Study Objective: To evaluate the efficacy and pleiotropic effects of prolonged-release melatonin used to treat insomnia in men with metabolic syndrome who work in shifts.

Study Design: This was a randomized, open-label, controlled study.

Materials and Methods: Group A included 26 men (mean age, 44; CI: 41.6-46.4) with confirmed metabolic syndrome who had worked shifts for more than 6 years. The control group included 23 apparently healthy age-matched men who worked in the daytime.

Study procedures included blood pressure (BP) and electrocardiogram monitoring and measurement of the degree of night-time BP reduction and circadian index. Other study procedures included measurements of triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), plasma glucose, and urinary 6-sulphatoxymelatonine and a subjective assessment of night-sleep quality.

Treatment included getting back to a normal sleep schedule and taking enalapril, amlodipine, and atorvastatin. After week 3, patients were randomized to subgroups A1 and A2. In subgroup A1, patients additionally received a 12-week course of prolonged-release melatonin.

Study Results: In group A, 6-sulphatoxymelatonine levels measured at night and at 4 a.m. were lower (р = 0.028 and 0.014, respectively) and those measured in the daytime were higher (p < 0.001) than in the control group. In subgroup А1, a normal sleep schedule was restored (22.5 points; CI: 21.40–23.30), circadian rhythms returned back to normal (night-time BP reduction 14.17%; CI: 14.16–14.74; circadian index 1.35; CI: 1.31–1.39), and TG (1.52 mmol/L; CI: 1.12–1.97) and HDL-C (1.28 mmol/L; CI: 1.18–2.07) also normalized. Waist circumference was reduced (p = 0.035).

Conclusion: Prolonged-release melatonin is an effective sleep medication that produces pleiotropic effects (restoration of normal circadian rhythms and lipid levels and obesity reduction).

Keywords: men, metabolic syndrome, shift work, melatonin, circadian rhythms.

Effects of Progesterone and its Analogs on the Functional Status of the Central Nervous System

  1. A. Ilovayskaya, D. S. Mikhaylova, V. Yu. Zektser

Objective of the Review: to discuss the effect of progesterone and some of its synthetic analogs on functioning of the central nervous system (CNS).

Key Points: Neurosteroid effects of the endogenous progesterone include sedative, anxiolytic, anticonvulsant and analgesic ones. The progesterone affects the brain by activating specific progesterone receptors that are widely distributed in CNS tissues. Progesterone protects CNS cells from physical and chemical damage, including brain trauma. Besides, progesterone derivatives (such as allopregnanolone and pregnenolone) have an intrinsic protective effect. Effects of synthetic progestins on the CNS differ from the profile of the endogenous progesterone, and this difference may be clinically significant.

Conclusion: Multiple experimental and clinical data indicate various effects of progesterone on brain cells. The fact that progesterone and synthetic progestins influence the CNS differently should be taken into account when choosing a gestagen component of hormonal therapy.

Keywords: progesterone, allopregnanolone, progestins, central nervous system, neurosteroids.

Doctor.Ru Gynecology Endocrinology No. 8 (125) ― No. 9 (126), 2017

First Results of Pan-Russian Project "Attitudes to Cancer in Middle-Aged Women: From Neglect to Phobia"

  1. I. Rogovskaya, S. P. Mashovets, N. B. Moskvina, V. G. Akimkin, N. V. Artymuk, T. N. Bebneva, T. E. Belokrinitskaya, N. I. Frolova, V. G. Volkov, A. G. Galenko, V. F. Dolgushina, I. D. Evtushenko, L. I. Korolenkova, M. S. Krapivina, I. I. Kukarskaya, E. Yu. Lebedenko, E. V. Ledin, A. V. Ledina, E. V. Lipova, N. V. Mingaleva, K. V. Minkevich, I. V. Molchanova, A. V. Mukhotina, A. I. Pashov, T. Yu. Pestrikova, N. M. Podzolkovа, V. V. Korennaya, V. E. Radzinsky, M. B. Khamoshina, E. A. Sandakova, L. V. Suturina, M. N. Tishina, L. V. Tkachenko, I. F. Fatkullin, G. I. Filippova, A. F. Mikhelson

Objective of Study Period I: 1) To study women's attitudes to their health, knowledge about cancer disorders and their prevention, screening examinations, and intake of hormones and 2) to evaluate how the degree of trust between patient and doctor influences these attitudes.

Study Design: This was a cross-sectional comparative clinical study.

Materials and Methods: A total of 1,826 women living in 24 Russian cities were asked to complete a specially designed questionnaire. An analysis included questionnaires completed by 991 respondents, aged 45 to 65. These respondents were divided into two groups. Group I consisted of 52.4% of women who worked in the healthcare industry; Group II included 47.6% of respondents who worked in other fields.

Study Results: Among respondents working in the healthcare industry, the most common attitude was reasonable alertness 77.1%, while phobias and neglecting behavior were seen only in 10.0% and 12.9% of women, respectively. Among respondents working in other fields, 49.8% of respondent showed reasonable alertness, while 26.3% of women were phobic and another 23.9% of women showed neglecting behavior. The proportion of women who trust their doctors is high both among healthcare and non-healthcare professionals: 75.9% and 66.5%, respectively. Overall, 8.5% of women working in the healthcare industry had positive attitude towards hormone therapy, 12.9% of respondents in Group I had unfavorable opinion about intake of hormones. In the group of non-healthcare professionals, 6.6% and 26.7% of participants showed favorable and unfavorable attitudes toward using hormones, respectively. The vast majority of respondents trusted their doctors to make the right choice of hormone therapy: 78.6% and 315 66.7% of women among healthcare and non-healthcare professionals, respectively.

Conclusion: The preliminary results of our study have revealed a low patient compliance to screening programs, a higher frequency of unfavorable opinions about hormone therapy among non-healthcare professionals, and a relatively high level of trust to doctors among all respondents.

Keywords: cancerophobia, neglecting behavior with respect to cancer, hormonophobia, questioning.

Management of Patients with Mild Cervical Dysplasia: Potentials of Argon-Plasma Ablation Therapy

  1. I. Rogovskaya, A. V. Ledina, T. N. Bebneva, A. Kh. Gaidarova

Objective of the Review: To assess the efficacy of argon-plasma ablation as treatment for low-grade cervical intraepithelial neoplasia.

Key Points: This paper summarizes currently available information about the diagnosis and treatment of low-grade squamous intraepithelial lesion (LSIL). It also describes the results of a study that evaluated the efficacy and safety of argon-plasma ablation as treatment for cervical intraepithelial neoplasia grade I/flat condyloma. This study showed a high efficacy and good tolerability of argon-plasma ablation. An examination performed 3 months after argon-plasma ablation showed complete clinical recovery of all 36 patients included in the study. LSIL relapsed in 2 (5.5%) women and occurred 6 and 9 months after treatment, respectively.

Conclusion: Minimal damage to the cervical epithelium, controlled depth of tissue destruction, the absence of extensive surgery scarring or post-treatment cervical defects, and a good tolerability of argon-plasma ablation suggest that this method can be widely used in practice. With the Fotek EA 141M device with parameter settings appropriately chosen and adjusted in consideration of the procedure's goals, specialists can perform a lot of diagnostic and therapeutic interventions that help to make an accurate diagnosis and choose effective management options.

Keywords: low-grade squamous cervical intraepithelial neoplasia, argon-plasma ablation, broadband radio wave surgery.

Insight into Anogenital Warts: Prevalence in Russia and Prevention

  1. A. Gomberg

Objective of the Review: To demonstrate that the actual prevalence of anogenital warts (AW) in Russia is underestimated and to describe an approach, based on world experience, to reduce the incidence of this condition through widespread immunization.

Key Points: Anogenital warts are caused by low-risk human papillomavirus (HPV) types and are officially recorded in Russia as an sexuallytransmitted infection (STI). Worldwide experience has shown that vaccination of both men and women with a quadrivalent vaccine that protects against the most common HPV types causing cancers and AW rapidly reduces the number of new cases of HPV infection and HPVassociated diseases. The primary sign of vaccine efficacy is a reduction in the number of reported cases of AW in the population.

Conclusion: Human papillomavirus causes various disorders, including cancers and AW, which are the most common STI in Russia. Within just a few years, widespread vaccination of both men and women with a quadrivalent vaccine can significantly reduce the incidence of HPVassociated disorders, primarily AW.

Keywords: anogenital warts, human papillomavirus, quadrivalent vaccine.

Anatomical Features of Pelvic-Floor Structures in Patients with Early Stages of Pelvic Organ Prolapse

  1. D. Dubinskaya, S. N. Kolesnikova, I. A. Babicheva, N. S. Pyatykh

Objective of the Paper: To assess the prognostic value of ultrasonography in female patients of reproductive age with early stages of vaginal wall prolapse stages I–II as assessed by the Pelvic Organ Prolapse Quantification (POP-Q) System.

Materials and Methods: The study included 240 women of reproductive age (28 to 42 years old) with vaginal wall prolapse POP-Q stages I–II, who were examined and treated between 2008 and 2015.

Study Results: Despite very mild clinical signs of pelvic organ prolapse at early stages in women of reproductive age, ultrasonography of the pelvic floor showed traumatic lesions of different relevant body structures almost in all patients with early stages of vaginal wall prolapse. Thus, pelvic ultrasonography helps detect structural changes in the urinary tract prior to the appearance of any clinical manifestations.

Conclusion: Ultrasonography is a readily available and informative method that can be used for timely detection of traumatic lesions, including postpartum lesions. Using this method will help identify women at higher risk of prolapse developing and worsening and personalize treatment approaches.

Keywords: pelvic organ prolapse, early stages, ultrasonography.

Prevention of Infectious Complications in Era of Antimicrobial Resistance

  1. B. Dikke, S. M. Semyatov, М. А. Soyunov

Objective of the Review: To identify main ways to prevent infectious complications in obstetrics and gynecology in the current context of increased antimicrobial resistance.

Key Points: The author used publicly available materials of the World Health Organization, Cochrane Collaboration, and guidelines of leading professional associations. The paper provides confirmed facts about antimicrobial resistance of some microorganisms; describes factors that contribute to the development of antimicrobial resistance and its increased prevalence; and includes guidelines on preventing infectious complications in obstetrics and gynecology published by leading world's professional associations, with the level of evidence and the strength of recommendations being specified.

Conclusion: In the era of increasing antibacterial resistance, the use of antibiotics for both preventive and therapeutic treatments should be very well justified. Any arbitrary decisions not supported by evidence-based information that lead to an unjustified use of antibiotics or, on the contrary, to non-administration of these medications when they are indicated are unacceptable.

Keywords: microorganisms, resistance, antibiotics, antibiotic prophylaxis.

New Treatment Options for Women with Uterine Leiomyoma and Reproductive Disorders

  1. F. Fatkullin, A. R. Bakanova, N. A. Ilizarova, A. A. Galeev

Study Objectives: To assess the efficacy of laparoscopic myomectomy as a tool to restore fertility in patients with intramural uterine leiomyoma who suffer from primary or secondary infertility; to clarify the indications for adjuvant therapy following myomectomy; and to use data obtained from our study and evidence-based scientific data in order to develop an optimal preconception care plan for patients with uterine leiomyoma, depending on the size and type of their myomas.

Study Design: This was a prospective, randomized, observational study.

Materials and Methods: The study included 126 women, aged 24 to 42 (mean age, 33.8 ± 4) with intramural uterine leiomyoma (types L3-L5 as assessed by the International Federation of Gynecology and Obstetrics classification; the mean size of fibroid was 4.4 ± 1.5 cm) who suffered from primary or secondary infertility. Participants were stratified sequentially into three groups (42 women in each group). In Group I, patients received Mifepristone, 50 mg daily for 4 months starting on day 8 post surgery. In Group II, women received triptorelin or leuprorelin, 3.75 mg intramuscularly every 28 days for 6 months starting on day 8 post surgery. The control group did not receive adjuvant therapy. The absence of a submucous portion was confirmed by diagnostic hysteroscopy. All patients underwent laparoscopic myomectomy. The uterine cavity was not opened during surgery, and the myoma bed was closed in layers. After surgery, all participants had regular transvaginal ultrasonography; they were regularly monitored and received consultations from a reproductive medicine specialist.

Study Results: The duration of follow-up ranged from 2 to 6 years; the mean follow-up was 3.5 years. After surgery, all women planned pregnancy. Overall, 52 women (41.3%) became pregnant after the procedure. The mean time from myomectomy to pregnancy was 14 ± 6 months. Forty-seven patients underwent cesarean section at term, and another 5 women were still pregnant at the time of writing of this article. Recurrences were observed in 48 (38.1%) of patients, who had small leiomyomas detected by ultrasonography. The mean time to the first recurrence was 26 ± 6 months and 25 ± 6 months in Groups I and II, respectively, vs. 15 ± 3 months in the control group. This study showed that chances of becoming pregnant after laparoscopic myomectomy are 3.5-fold lower (p = 0.03, 95% confidence interval [CI]: 2.8–4.3) in patients older than 40 years and 1.6-fold lower in patients aged 35 to 40 (p = 0.02, 95% CI: 1.2–2.3). Patients with leiomyoma recurrence after myomectomy have 2.05-fold lower chances to get pregnant (p = 0.045, 95% CI: 1.56-2.45); for women with other causes of infertility, these chances are 1.4-fold lower (p = 0.045, 95% CI: 1.20–1.65).

Conclusion: In infertile patients with uterine leiomyomas, laparoscopic removal of intramural lesions helped restore fertility in 41.3% of cases. After myomectomy, women aged 24 to 34 have the best reproductive prognosis for 6􀍵24 months post surgery. After 24 months, this prognosis significantly worsens, probably, due to an increased rate of recurrence. Women who are at high risk of leiomyoma recurrence and those who have to postpone their reproductive plans should receive adjuvant therapy.

Keywords: uterine leiomyoma, laparoscopic myomectomy.

Noninvasive Prenatal Determination of Fetal Gender and Rhesus Factor: Results of Multicenter Study

  1. N. Toporovsky, A. G. Nikitin, D. A. Viktorov, A. G. Konoplyannikov

Objective of the Paper: To assess a method used to determine the fetal gender and Rhesus (Rh) factor at early stages of pregnancy using maternal blood.

Materials and Methods: The authors evaluated plasma samples taken from pregnant women between weeks 10 and 30 of pregnancy. Overall, 1,423 samples were used to determine the fetal gender and 1,680 samples taken from Rh-negative women were used to determine the fetal Rh status.

Results: This study showed that real-time polymerase chain reaction (PCR) as a tool of prenatal determination of the fetal gender and Rh factor status (in Rh-negative women), based on the evaluation of circulating DNA obtained from maternal plasma, is highly sensitive and specific. This method can be used by clinical PCR-laboratories provided that the kits' manufacturer's recommendations are followed.

Conclusion: The results of this analysis and clinical and laboratory examination findings obtained during pregnancy may help doctors prescribe anti-Rh0(D) immunoglobulin as a preventive treatment.

Keywords: prenatal diagnosis, nonivasive diagnosis, diagnostic molecular genetic testing, fetal Rh factor, fetal gender.

Simultaneous Operation for Inflamed Meckel's Diverticulum During Third Trimester of Pregnancy

  1. D. Dibirov, Yu. D. Vuchenovich, M. I. Vasilchenko, T. Yu. Sych, A. L. Tikhomirov, A. N. Krizhanovskaya

This paper describes a clinical case of a simultaneous operation performed at week 37 of gestation in a pregnant female patient with an inflamed Meckel's diverticulum. Pregnant patient M., 45 years old, presented with periodic aching pain in the infrahepatic abdomen, nausea, fever up to 37.8° С, and weakness. Conservative treatment did not lead to any improvement, and a decision was made to proceed with operative delivery and exploration of the abdominal cavity. Laparotomy was performed followed by cesarean section using the Joel-Cohen incision. Further exploration revealed an inflamed Meckel's diverticulum, which was excised by performing a wedge resection.

The diagnosis of diverticulitis is extremely challenging, especially in pregnant women. It's explained by changes in the anatomic relationships between internal organs, inflammatory response during pregnancy, and significant variability and subtleness of clinical signs of surgical emergencies. This clinical case shows that a Meckel's diverticulum can be detected when it is already complicated.

Keywords: small-intestine diverticulum, Meckel's diverticulum, resection of diverticulum, pregnancy.

Modern Prognostic Models for Risk Stratification of Thyroid Cancer

  1. V. Novosad, M. O. Rogova, N. S. Martirosyan, N. A. Petunina

Thyroid nodular disease (TND) has been recognized as the most common endocrine disorder. The percentage of malignant thyroid nodules is constantly increasing. Despite numerous management guidelines for patients with TND, the choice of appropriate treatment still presents certain challenges. In all countries, specialists are now actively trying to develop and implement new more effective and economical medical technologies. The authors discuss in detail the reasons for the increase in thyroid cancer incidence and describe the Thyroid Imaging Reporting and Data System and modern prognostic models based on an integration of clinical, pathological, biochemical, and ultrasound risk factors, which allow to assess the risk of malignancies for each individual patient.

Keywords: thyroid nodular disease, thyroid cancer, Thyroid Imaging Reporting and Data System, nodular goiter.

Association Between Sleep and Metabolic Disorders in Patients with Polycystic Ovary Syndrome

  1. S. Absatarova, E. V. Sheremetieva, E. N. Andreeva

Study Objective: To study the association between sleep and metabolic disorders in patients with polycystic ovary syndrome (PCOS) and to provide data that would prove the efficacy of using melatonin as part of a combination treatment regimen in this patient population.

Materials and Methods: The study included 60 patients with PCOS and 60 healthy women (control group). At stage I, we selected 30 patients with PCOS and body mass index (BMI) ≥ 25 kg/m2 (subgroup 1) and 30 patients with PCOS and BMI < 25 kg/m2 (subgroup 2). Subgroup 3 included 30 healthy women with BMI ≥ 25 kg/m2, subgroup 4 consisted of 30 healthy women with BMI < 25 kg/m2. All study participants completed a questionnaire specifically designed to assess the severity of sleep disorders. Other study examinations included blood chemistry (glucose and lipid profile) and hormone tests (insulin, luteinizing hormone, follicle-stimulating hormone, and testosterone). In addition, insulin resistance was determined by the Homeostasis Model Assessment. As it was indicated, patients with PCOS received a combined oral contraceptive containing drospirenone, ethinyl estradiol, and calcium levomefolate. They were also given metformin and a synthetic analogue of melatonin.

Study Results: Women with PCOS had significant dyslipidemia, insulin resistance, and hyperandrogenemia. Overall, 70% of patients with BMI < 25 kg/m2 had sleep disorders, which tended to correlate in severity with in sulin level. Melatonin helped effectively treat sleep disorders.

Conclusion: Polycystic ovary syndrome requires a multidisciplinary approach with an assessment for sleep disorders as an essential component. Such patients require long-term medical follow-up.

Keywords: polycystic ovary syndrome, hyperandrogenemia, insulin resistance, melatonin, sleep.

Doctor.Ru Gastroenterology No. 10 (127), 2017

Diagnosis and Treatment of Helicobacter pylori-Associated Disorders Using Results of 2015 Kyoto Global Consensus Meeting

  1. V. Maev, D. N. Andreev, A. A. Samsonov, D. T. Dicheva

Objective of the Review: To describe the results of the Kyoto Global Consensus Meeting (2015), which focused on raising awareness of the current classifications of gastritis associated with Helicobacter pylori (HP) infection, analyzing the role of this disorder in the development and progression of precancerous changes in the gastric mucosa (GM), and discussing the possibilities of early diagnosis of HP infection and HP eradication therapy (ET) as means of cancer prevention.

Key Points: HP-associated gastritis should be considered a separate infectious disease, even if the patient has no complaints, and regardless of the presence of peptic ulcer or cancer. In patients with HP infection associated with dyspepsia, symptoms can be caused by persistence of infection; a long symptom-free period after ET is a sign of HP-associated dyspepsia, which is a separate entity. HP infection is the main cause of gastric cancer. The risk for gastric cancer correlates with the severity and extent of atrophic gastritis. Using the Operative Link for Gastritis Assessment and the Operative Link on Gastric Intestinal Metaplasia Assessment histological staging systems as well as serum markers (pepsinogen I, pepsinogen II, and anti-HP antibodies) helps stratify the risk for gastric cancer. Eradication of HP reduces this risk. The degree of risk reduction depends on the presence, severity, and extent of atrophy at baseline (prior to ET). In terms of cancer prevention, ET is most effective when administered prior to the appearance of gastric mucosa atrophy.

Conclusion: The Kyoto Global Consensus Meeting has played a key role in the current understanding of HP-associated gastritis and in identifying approaches to its management. It provided an algorithm that helps clearly distinguish organic (HP-associated) and functional dyspepsia. In real-life practice, this algorithm allows specialists to use adequate therapies suitable for specific disorders.

Keywords: Helicobacter pylori, gastritis, dyspepsia, functional dyspepsia, atrophic gastritis, intestinal metaplasia, eradication.

Helicobacter рylori Infection in Children with Type I Diabetes Mellitus

  1. A. Nizhevich, G. M. Yakupova, O. A. Malievskiy, V. A. Malievskiy, V. U. Sataev, D. S. Valeeva, D. S. Nurmukhametova, R. A. Akhmetova

Study Objective: To estimate the prevalence of chronic gastroduodenal pathology associated with Helicobacter pylori (HP) in children with type I diabetes mellitus (T1DM).

Study Design: This was an open-label prospective study.

Materials and Methods: Clinical observation and specific examinations covered 139 children. The main group included 108 patients with T1DM (61 girls and 47 boys), aged from 5 to 17 (the mean age was 13.1 ± 1.9). The children were divided into two subgroups by the duration of diabetes: subgroup I included 57 children with a history of diabetes of 5 years or less; subgroup II included 51 children with a history of T1DM of more than 5 years. The control group included 31 children with chronic gastroduodenal pathology — 19 girls and 12 boys without diabetes mellitus, aged from 5 to 17 (the mean age was 12.7 ± 1.4). Together with the traditional histological method, a modern HpSA test was used to diagnose HР infection.

Study Results: Histological analysis detected HP bacterial bodies in 19 (33.3%) patients from subgroup I, 31 (60.8%) children from subgroup II, and 23 (74.2%) children from the control group. The biopsy urease HELPIL-test gave a positive result in 16 (28.1%) patients from subgroup I and in 29 (56.9%) children from subgroup II. A comparison of the total number of HP-infected patients in both subgroups of the main group with that in the control group — 45 (41.7%) vs. 21 (67.7%) — showed that children without T1DM were more often infected with HP than children with T1DM (p = 0.009). The HpSA test confirmed HP infection in 17 (29.8%) and 29 (56.9%) children from subgroups I and II, respectively, and in 21 (67.7%) children from the control group.

Conclusion: In patients with T1DM, the role of HP infection in the development of gastrointestinal tract disorders is not as significant as in patients with clinical signs of dyspepsia. In children with T1DM, non-invasive tests should be preferred over invasive diagnostics of pyloric HP infection.

Keywords: children, type I diabetes mellitus, Helicobacter pylori.

Diabetes Mellitus and New Point of View: from Hepatic Steatosis to Fibrosis

  1. G. Bakulin, Yu. G. Sandler, E. V. Vinnitskaya, V. A. Keiyan, S. V. Rodionova

Study Objective: To perform a screening evaluation of hepatic steatosis and fibrosis in patients with type 2 diabetes mellitus (T2DM) by non-invasive methods — liver transient elastography (TE) and fibrotests (FT); and to determine the diagnostic value of TE, FT and factors that promote hepatic fibrosis.

Study Design: This was a prospective single-site open-label clinical study.

Materials and methods: Sixty-seven patients, aged from 30 to 82, with T2DM underwent a thorough examination. Statistic analysis included ROC-analysis, correlation analysis, single-factor ANOVA, and multiple logistic regression.

Study Results: Hepatic cirrhosis was found in 11.9% of the patients by each study method. The accuracy of TE and FT in determining the F4 stage was considered very high (AUROC 0.86 in both cases). Clinically significant hepatic fibrosis (F2) was found in 21% by both TE and FT. Such factors as male gender, elevated levels of alanine aminotransferase, steatosis, obesity, and the activity of necrosis and inflammation contribute to the development of hepatic fibrosis.

Conclusion: In patients with non-alcoholic fatty liver, T2DM is a risk factor for clinically significant hepatic fibrosis. Given the risk of development and progression of hepatic fibrosis, patients with T2DM need a more elaborate examination and a closer medical attention. TE and FT showed a comparably high accuracy in diagnosing hepatic cirrhosis in patients with T2DM.

Keywords: hepatic fibrosis, type 2 diabetes mellitus, non-alcoholic fatty liver, non-invasive methods, transient elastography, fibrotests, AUROC.

Capsule Endoscopy as Screening Method for Examining Gastrointestinal Tract in Outpatient Settings: Model of Reference Centers

  1. L. Shcherbakov

Purpose of the Paper: To show the value of video capsule endoscopy as a highly informative method for examining gastrointestinal (GI) mucosa.

Key Points: Video capsule endoscopy allows visual examination of the entire GI tract with subsequent data analysis, while ensuring the high quality of life. The analysis and the interpretation of the results may be delayed and/or remote from the patient and may take place in reference centers. The examination itself is possible in any medical facility (hospital, outpatient clinic, rural health post, etc.).

Conclusion: The evaluation of GI mucosa by video capsule endoscopy is highly informative and relatively simple from the technical point of view; it also ensures the high quality of life. This examination can be done in any place, irrespective of its remoteness from expert centers that interpret the obtained data.

Keywords: video capsule, mucosa, gastrointestinal tract, reference center.

Levels of Growth Factors in Tissues of Esophageal Squamous-Cell Carcinoma: Gender Differences

  1. I. Kit, E. M. Frantsiants, E. N. Kolesnikov, N. D. Cheryarina, L. S. Kozlova, Yu. A. Pogorelova

Study Objective: To study the levels of growth factors in tissues of esophageal squamous-cell carcinoma (ESCC), its peritumoral area (PA) and surgical margins in men and women.

Study Design: This was a prospective comparative study.

Materials and Methods: Tissues collected from 32 patients with stage II ESCC (G2, рTNM) — 21 men and 11 women (all women were menopausal), aged from 38 to 74 — were examined by enzyme immunoassay. The following factors were measured: vascular endothelial growth factors (VEGF-А and VEGF-C) and their receptors, epidermal growth factor (EGF), transforming growth factor (TGF-β1), and insulinlike growth factors (IGF-1 and IGF-2).

Study Results: Compared to women, men had significantly higher (p < 0.05) levels of all studied growth factors in surgical margins, except for VEGF-С and IGF-2. In men, VEGF-А, VEGF-R1, and VEGF-С levels in tumor tissues were almost 10-fold higher than in women; TGF-β1 levels were also higher (p < 0.05 for all comparisons). VEGF-R3, EGF, and IGF levels in men and women did not differ. PA levels of VEGF-R1, TGF-β1, and IGF-1 were significantly higher in men than in women (p < 0.05); PA levels of VEGF-А, VEGF-R3, EGF, and IGF-2 were similar in men and women, and VEGF-С levels in men were several times lower than in women.

Conclusion: In patients with ESCC, gender differences in the levels of growth factors and VEGF receptors are mainly seen in surgical margins. Quantitative changes in the levels of these factors in ESCC tissues are in-sync, unidirectional, and dependent on their baseline levels in surgical margins. Unlike in men, in women, PA levels of most of these factors significantly exceed their levels in surgical margins, but do not differ significantly from their levels in ESCC tissues.

Keywords: growth factors, gender differences, esophageal squamous-cell carcinoma.

Low Prevalence of Peptic Ulcer in Mongoloids Living in High Latitudes: Northern Paradox?

  1. V. Tsukanov, E. V. Kasparov, Yu. L. Tonkikh, A. V. Vasyutin, E. P. Bronnikova

Study Objective: To investigate the relationship between the prevalence of Helicobacter pylori infection and peptic ulcer in native and nonnative residents of Evenkia.

Study Design: cross-sectional study.

  1. Materials and Methods: The prevalence of peptic ulcer was assessed based on fiberoptic esophagogastroduodenoscopy data obtained from a 30% random sample comprising 1,114 Caucasians (553 men and 461 women) and 792 Evenks (379 men and 413 women) living in Evenkia. The presence of H. pylori was examined in 689 Caucasians and 493 Evenks by three different methods: a morphological analysis and a urease test performed on biopsy samples taken from the antral stomach, and an evaluation of serum anti-pylori IgG and anti-CagA IgG antibodies by enzyme immunoassay.
  2. Study Results: These examinations showed that 8.8% of Caucasians and 1.0% of Evenks (р < 0.001) had peptic ulcer. The prevalence of Н. pylori infection was similar in both populations — 88.8% in Caucasians and 88.6% in Evenks. In Caucasians, anti-H. pylori IgG antibodies were associated with peptic ulcer; in Evenks, the difference between the numbers of carriers of pylori with and without peptic ulcer was not statistically significant because of the small group size. However, in Evenks the presence of anti-CagA IgG antibodies was associated with ulcer defects in a statistically significant manner, while in Caucasians this association was not observed.
  3. Conclusion: We found that the prevalence of peptic ulcer in the native population of Evenkia is significantly lower than in Caucasians living on this territory, while the frequency of pylori infection is similarly high in these groups. We believe that this paradox can be explained by the fact that native residents have powerful mechanisms of gastric protection from aggressive factors.

Keywords: peptic ulcer, Helicobacter pylori, prevalence.

Self-Expanding Stents in Treating Gastric Outlet Obstruction

  1. L. Shcherbakov, A. A. Arkhipov, O. A. Shchipkov

Purpose of the Paper: To show the potentials and applications of self-expanding stents.

Key Points: This publication analyzes the efficacy of stenting the gastric outlet and the first portion of the duodenum as a palliative treatment of malignant gastroduodenal obstruction and describes the authors’ experience with this technique in patients with such conditions.

Conclusion: Using self-expandable stents in gastroduodenal malignant tumors is a feasible, safe and effective method, especially for patients with a limited life expectancy. This measure allows improving both the nutritive process and the quality of life.

Keywords: malignant gastric tumor, endoscopy, stenting.

Abdominal Compartment Syndrome in Acute Pancreatitis: Literature Review

  1. S. Fomin, A. I. Isaev, L. V. Domarev, A. B. Dzhadzhiev, A. M. Magomedaliev

Objective of the Review: To summarize current insights into intra-abdominal hypertension in acute pancreatitis.

Key Points: The authors describe the following issues: degree of intra-abdominal pressure, and causes, pathophysiological mechanisms, treatment, and prevention of intra-abdominal hypertension in patients with acute pancreatitis.

In surgical patients, abdominal compartment syndrome is most often associated with so-called visceral edema, pneumoperitoneum, and an increase in the amount of intra-abdominal fluid. In most cases, indirect intravesical manometry is the "gold standard" for measurement of intra-abdominal pressure. It is now recognized that the severity of abdominal compartment syndrome is directly related to the degree of intra-abdominal hypertension and the rate of pressure increase, which is associated with multiorgan abnormalities.

Conclusion: The high rates of complications and deaths in patients with acute pancreatitis complicated by abdominal compartment syndrome and the multidisciplinary nature of this combination of disorders readily explain the need for new methods of conservative, minimally invasive, and conventional surgical treatment for this cohort of severe patients.

Keywords: acute pancreatitis, intra-abdominal hypertension, enteral and multiorgan failure.

Using Parenteral Nutrition Containing ω3-Fatty Acids for Treatment of Metabolic Disorders in Surgical Patients

  1. G. Arykan, V. V. Stets, V. A. Zyryanov, M. D. Lyubimov, A. E. Shestopalov

Study Objective: To assess the efficacy of postoperative parenteral nutrition (PN) with the SMOFKabiven-central "3 in 1" system in treating metabolic disorders in patients with lower esophagus cancer.

Study Design: This was a prospective controlled comparative randomized study.

Materials and Methods: Patients with tumors of the lower esophagus (43 males aged 67.9 ± 10.5) were divided into two groups, depending on the regimen of PN they received in the postoperative period: Group 1 received Kabiven-central, and Group 2 received SMOFKabiven-central. The duration and the nutritive value of enteral nutrition were the same in both groups. The efficiency of nutrition support was assessed on Days 1, 3, 5, 7, and 10 after surgery by measuring certain parameters of the protein, fat, and carbohydrate metabolism.

Study Results: Both groups showed unidirectional changes in the metabolic parameters during the period of full parenteral nutrition and the subsequent period of combined parenteral/enteral nutrition. However, in Group 2 these changes occurred more rapidly (on Days 5–7) than in Group 1 (on Day 10).

Conclusion: Because of its high antioxidant content and a unique composition of its fat emulsion, SMOFKabiven can be used as an effective treatment of metabolic disorders in the early postoperative period.

Keywords: parenteral nutrition, metabolism, ω3-fatty acids, antioxidants, oncology.

Causes of Post-Procedural Pancreatitis: Literature Review

А. E. Klimov, M. V. Petrova, E. Yu. Sadovnikova, M. Yu. Persov, A. A. Barkhudarov, S. S. Andreev

Objective of the Review: To summarize information from current publications about the causes of acute pancreatitis that develops after endoscopic procedures on the pancreatic ductal system and the biliary tree.

Key Points: Disorders of the hepato-pancreato-biliary system are highly prevalent and are often associated with abnormalities of the major duodenal papilla and the sphincter of Oddi. This explains the high prevalence of minimally invasive endoscopic interventions and procedures in patients with these disorders. Such interventions often cause various complications, including acute post-procedural pancreatitis. We investigated potential causes of this complication.

Conclusion: A great variety of causes of acute post-procedural pancreatitis in people who underwent different transpapillary procedures supports the need for further scientific search for ways to improve treatment outcomes in patients with hepato-pancreato-biliary disorders as well as for the development of methods to prevent complications of transpapillary procedures.

Keywords: transpapillary interventions, post-procedural pancreatitis, prevention of complications, review of causes.

Laser Treatment for Benign Stenosis of Major Duodenal Papilla

  1. V. Levchenko, V. V. Khryachkov, R. R. Shavaliev

Study Objective: To develop and implement a new minimally invasive method of papillotomy — an antegrade dissection of the major duodenal papilla (MDP) using high-energy holmium (YAG:Ho) laser.

Materials and Methods: Thirty-one patients who were treated at the Surgery Department of the Nyagan District Hospital underwent surgery. To perform surgery with our technique of antegrade laser papillotomy (ALPT), we used high-energy YAG:Ho laser, endoscopic video-assisted surgery systems, and a fiberoptic choledochoscope. An intraoperative choledochoscopy and, if indicated, ALPT was performed during cholecystectomy.

Study Results: All patients with MDP stenosis underwent successful ALPT; 15 of these patients (48.4%) had MDP stenosis associated with choledocholithiasis. All surgical procedures were laparoscopic, no indications for conversion were found. The desired result was obtained in all cases. No fatal outcomes were reported. Five patients had a complication (increased blood levels of amylase), which was successfully treated by conservative therapy.

Conclusion: The study results showed sufficiently high efficacy of using antegrade papillotomy as a treatment for MDP stenosis. High-energy holmium laser helps perform an adequate papillotomy with minimal damage to the surrounding tissues. This surgery is effective even when endoscopic retrograde sphincterotomy of the papilla of Vater is impossible.

Keywords: choledocholithiasis, major duodenal papilla stenosis, choledochoscopy, laser lithotripsy, antegrade laser papillotomy.

Doctor.Ru Cardiology Internal Medicine No. 11 (128), 2017

Preventing Early Vascular Aging in Obese Patients Who Are Receiving Angiotensin-Converting Enzyme Inhibitors

  1. V. Nedogoda, R. V. Palashkin, A. A. Ledyaeva, E. V. Chumachyok, V. O. Smirnova, V. Yu. Khripaeva

Study Objective: To compare two angiotensin-converting enzyme (ACE) inhibitors, perindopril and enalapril, in order to assess their efficacy in preventing early vascular aging.

Study Design: This was a single-blind randomized comparative study.

Materials and Methods: This 24-week parallel-group study included 60 overweight patients with hypertension, aged 40 to 65. The study was designed to assess the effects of perindopril 10 mg/day and enalapril 20 mg/day on systolic blood pressure (SBP), diastolic blood pressure (DBP), blood-chemistry parameters, anthropometric measurements, vascular age, and arterial wall elasticity. Each study group consisted of 30 patients.

Study Results: The study showed that perindopril was more effective in reducing 24-hour, daytime, and nighttime SPB and DBP and heart rate (HR) than enalapril (p < 0.05 for all comparisons). Treatment with perindopril was associated with a significantly greater improvement in lipid, carbohydrate, and purine metabolism, anthropometric measurements, and vascular elasticity. In addition, perindopril reduced noninfectious inflammation.

Over a 24-week treatment period, perindopril caused a greater reduction in vascular age than enalapril: 5 vs. 2.8 years.

Conclusion: Perindopril is a better option to prevent early vascular aging in overweight patients with hypertension.

Keywords: early vascular aging, vascular stiffness, hypertension, perindopril.

Anticoagulation Therapy in Patients with Non-Valvular Atrial Fibrillation: Effects of Apixaban

  1. L. Barbarash, V. V. Kashtalap

Objective of the Review: To describe data about Apixaban obtained from some subanalyses performed in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) randomized clinical study, which can be useful for practitioners when choosing use new oral anticoagulants for long-term prevention of ischemic events in patients with atrial fibrillation (AF).

Key Points: This paper analyzes the advantages of Apixaban over warfarin in terms of efficacy and safety in patients with non-valvular AF in different clinical settings (advanced age, renal dyfunction, cardiovascular comorbidity, concomitant treatments, and high risk of hemorrhage). This analysis is based on the results of the subanalyses performed in the ARISTOTLE clinical study.

Conclusion: The results of numerous subanalyses performed in the ARISTOTLE international randomized study suggest that, due to a unique combination of its efficacy and safety, Apixaban (Eliquis) can be recommended for long-term anticoagulation therapy in patients with AF and a wide range of concomitant disorders and clinical conditions that increase the risk of thrombotic, ischemic, and hemorrhagic events.

Keywords: atrial fibrillation, anticoagulation therapy, new oral anticoagulants, Apixaban, comorbidity.

Clinical Significance of Collateral Coronary Blood Flow in Patients with Ischemic Heart Disease

  1. V. Kozlova, I. V. Starostin, O. S. Bulkina, V. V. Lopukhova, Yu. A. Karpov

Objective of the Review: To summarize the data of published studies that evaluated the role of collateral blood flow in ischemic heart disease (IHD), associated factors, and potential ways to change such blood flow.

Key Points: In patients with IHD, collateral blood flow is a natural way to compensate disturbed blood supply to ischemic myocardium. In these patients, good collateral blood flow is associated with a better prognosis. Many modifying and non-modifying factors that contribute to the development of collateral flow have been identified. Methods that would change collateral circulation are now being developed.

Conclusion: Studies aimed to find safe and effective ways to improve collateral blood flow in patients with IHD should be continued.

Keywords: ischemic heart disease, collateral blood flow, arteriogenesis.

Diagnostic Value of Measuring Modified Immunoglobulins G in Patients with Coronary Artery Atherosclerosis

  1. Kh. Shogenova, R. A. Zhetisheva, M. R. Kabardieva, A. M. Karpov, E. E. Efremov, V. P. Masenko, V. G. Naumov

Study Objective: To evaluate the diagnostic value of measuring low-density malondialdehyde- and methylglyoxal-modified low-density lipoprotein (MDA-LDL and MG-LDL) and malondialdehyde- and methylglyoxal-modified immunoglobulins G in patients with coronary artery atherosclerosis.

Materials and Methods: The study included three groups of male patients: patients with severe coronary artery stenosis (> 50%) confirmed by angiography (n = 50); patients with early signs of coronary artery atherosclerosis (≤ 50%, n = 20); and apparently healthy patients who did not have ischemic heart disease (n = 10). Serum levels of methylglyoxal- and malondialdehyde-modified low-density lipoproteins (MG-LDL and MDA-LDL) and malondialdehyde- and methylglyoxal-modified IgG (MDA-IgG and MG-IgG) were measured by enzyme-linked immunosorbent assay (ELISA).

Study Results: No significant difference in the levels of MDA-LDL and MG-LDL were seen between the study groups. However, in healthy people MG-IgG and MDA-IgG titres were significantly higher than in patients with severe coronary artery atherosclerosis (р = 0.02 and р = 0.01, respectively). In all subjects, a strong correlation was observed between MDA-LDL and MG-LDL levels (r = 0.62; p = 0.0000) and between MDA-IgG and MG-IgG levels (r = 0.79; p = 0.0000). There was also a moderate correlation between MDA-LDL, MG-LDL, MDA-IgG, and MG-IgG levels.

Conclusion: In our clinical study, patients with significant coronary artery atherosclerosis had lower levels of MDA-IgG and MG-IgG than healthy young people. Our results support the suggestion that the person's age, immune status, and metabolic rate may affect their serum levels of MDA-IgG and MG-IgG. The correlation between MDA-LDL/MG-LDL and MDA-IgG/MG-IgG levels suggests that modified IgG can be used together with modified LDL in investigating aldehyde-mediated chemical modifications of proteins.

Keywords: atherosclerosis, oxidized low-density lipoproteins, modified low-density lipoproteins, inflammation.

Cardio-Ankle Vascular Index in Patients with Hypertension

  1. N. Sumin, A. V. Shcheglova, N. V. Fyodorova, G. V. Artamonova

Study Objective: To evaluate the frequency of detecting abnormal cardio-ankle vascular index (CAVI) values in patients with hypertension and factors associated with these abnormal values, based on the results of the ESSE-RF (Epidemiology of Cardiovascular Diseases in the Regions of the Russian Federation) study obtained in Kemerovo Region.

Materials and Methods: The study was performed in a random sample of 2,000 males and females, aged 25 to 64. The percentage of subjects who agreed to participate in the study was 81.4% (1,628 subjects). Overall, 1,595 (98%) of patients had volume sphygmography accompanied by automatic measurement of CAVI. A total of 709 patients with hypertension (blood pressure [BP] ≥ 140/90 mm Hg or < 140/90 mm Hg in those receiving antihypertensive therapy) were divided into two groups, depending on their CAVI values: in Group 1 (n = 124) CAVI was ≥ 9.0, in Group 2 (n = 585) it was < 9.0.

Study Results: Higher CAVI values were associated with a more advanced age (р < 0.001). Patients with CAVI ≥9.0 had significantly higher blood levels of creatinine (р = 0.019) and uric acid (р = 0.024) than those whose CAVI was < 9.0. In Group 1, BP was significantly higher than in Group 2: systolic BP 153.0 (143.5; 167.8) mm Hg vs. 145.5 (134.0; 156.0) mm Hg and diastolic BP 95.8 (88.8; 105.8) mm Hg vs. 92.0 (84.0; 100.0) mm Hg (р < 0.001 for both comparisons). A multivariate analysis identified the following two strong independent predictors of high CAVI: age (odds ratio [OR] 1.08; 95% confidence interval [CI]: 1.05–1.10; р <0.001) and blood creatinine levels (OR 1.02; 95% CI: 1.0–1.03; р = 0.0021).

Conclusion: Overall, 17.5% of patients with hypertension had abnormal CAVI values. Independent factors associated with these abnormal values were the patient's age and blood creatinine level. In patients with hypertension, evaluation of CAVI helps identify patients at higher risk of cardiovascular complications and assess the efficacy of medication treatment. It is also useful in risk factor management as part of preventive strategies.

Keywords: cardio-ankle vascular index, hypertension.

Role of Autonomic Nervous System in Development of Fatal Rhythm Disturbances in Patients with Ischemic Heart Disease

  1. O. Lysenkova, M. I. Rumyantsev, A. E. Kratnov

Objective of the Review: To describe myocardial instability in patients with ischemic heart disease (IHD).

Key Points: Epidemiological, clinical and morphological data show clearly that there is a strong correlation between cardiac death and specific effects of the autonomic nervous system on the heart function in patients with IHD. In such patients, anatomical and functional changes in the myocardium cause a significant reorganization of the autonomic nervous system.

Conclusion: A mismatch between electrophysiological processes in the myocardium, efferent impulses from the central structures, and the state of afferent inputs as well as dysfunction of the central nervous structures may cause electrical myocardial instability and contribute to fatal rhythm disturbances resulting in cardiac death.

Keywords: autonomic nervous system, ischemic heart disease, cardiac death, heart rhythm disturbances.

Using Structural and Geometric Parameters of Left Ventricle in Evaluation of Cardiac Electrical Remodeling in Patients with Diabetes Mellitus

  1. G. Denisova, I. P. Tatarchenko, N. V. Pozdnyakova

Study Objective: To study the parameters of cardiac structural and functional remodeling in patients with type 2 diabetes mellitus (T2DM) with regard to cardiovascular risk factors.

Study Design: This was an open-label, randomized, parallel-group study.

Materials and Methods: The study included 165 patients with T2DM. Group I (n = 40) included patients with no history of cardiovascular disorders; Group II (n = 60) included patients with grade 1-2 hypertension; and Group III (n = 65) was made up of patients with ischemic heart disease (IHD) and hypertension. A comprehensive examination included: echocardiography, electrocardiogram (ECG) Holter monitoring, 24-hour blood pressure monitoring, detection of late-ventricular potentials in the signal-averaged ECG, and an analysis of heart-rate variability and turbulence.

Study Results: Left ventricular (LV) hypertrophy was detected in 45%, 86.7%, and 100% of patients in Groups I, II, and III, respectively. Compared to other study subjects, patients with T2DM, hypertension and IHD more often had pseudonormal (30.7%) and restrictive (18.5%) filling patterns of LV diastolic dysfunction and more frequently showed clinical signs of chronic heart failure (86.2%) and grade III-V ventricular extrasystoles (44.6%). Overall, 33.8% of patients in Group III had late ventricular potentials, and 30.8% of patients in this group had abnormal turbulence slope (TS) (TS < 2.5 ms/RR). A total of 29.2% of patients in Group III had turbulence onset (TO) of more than 0%.

Conclusion: Left ventricular hypertrophy and remodeling cause LV diastolic dysfunction and contribute to the worsening of heart failure and the development of electrical myocardial instability.

Keywords: diabetes mellitus, remodeling, left ventricular diastolic dysfunction.

First Polytablet: Fixed-Dose Combination of Angiotensin-Converting Enzyme, Calcium Antagonist, and Statin

  1. V. Nedogoda

Objective of the Review: To analyze the potential uses of a fixed-dose combination of amlodipine, lisonopril, and rosuvastatin in treating patients with hypertension.

Key Points: Evidence-based medicine has shown that a combination of amlodipine and an angiotensin-converting enzyme is the combination of choice for hypertensive patients who are at high risk of cardiovascular complications, including those who have diabetes, microalbuminuria, overt proteinuria, and end-organ damage. Rosuvastatin reduces levels of low-density lipoproteins by 40-50%, decreases triglycerides, and increases high-density lipoproteins. In addition, rosuvastatin produces a number of beneficial pleiotropic effects in non-cardiac diseases. Some studies showed that a combination of amlodipine and statin helps most effectively achieve target levels of lipids and blood pressure due to the synergistic effect of its components.

Conclusion: This groundbreaking fixed-dose combination helps implement the polypill strategy into real-world clinical practice and achieve the greatest reduction in cardiovascular risk, estimated to be up to 80%.

Keywords: hypertension, high cardiovascular risk, combination antihypertensive therapy, amlodipine, lisonopril, rosuvastatin.

Specific Clinical Features of Chronic Venous Disease in Women with Hypotension

  1. M. Baev, O. A. Samsonova, T. Yu. Agafonova, R. Sh. Dusakova

Study Objective: To assess specific clinical features of lower-limb chronic venous disease (CVD) in young women with idiopathic hypotension.

Study Design: This was a cross-sectional, non-randomized study.

Materials and Methods: The frequency of subjective symptoms of CVD, the severity of this disorder, and the intensity of its manifestations was compared between two groups. The main group included 41 women with systolic blood pressure (BP) of 93–98 mm Hg; the control group consisted of 19 patients with systolic BP of 121–125 mm Hg. In both groups, the diagnosis of CVD was made after scanning of lower-limb veins, based on the presence of reflux during proximal compression and the Valsalva maneuver.

Study Results: Women with idiopathic hypotension more often reported pain in legs (46.3%; р = 0.046), moderate leg edema (15%), and mild venous claudication (6%).

Conclusion: Because of their low blood pressure, women with idiopathic hypotension have more severe clinical signs of CVD compared to women with normal blood pressure. This study revealed specific clinical features of CVD in patients with idiopathic hypotension, which should be used for early detection of CVD in this group of patients.

Keywords: young women, idiopathic hypotension, lower-limb veins.

Correlation Between Cardiac Functional Status and Severity of Pulmonary Hypertension in Patients with Lung Diseases

  1. N. Titova, N. A. Kuzubova, A. L. Alexandrov, V. E. Perley, A. Yu. Gichkin

Study Objective: To assess the role of pulmonary hypertension (PH) in the development of structural and functional abnormalities in the right heart chambers.

Study Design: This was a retrospective analysis.

Materials and Methods: This paper is based on the results of a retrospective analysis of Doppler echocardiography findings obtained in 981 patients with chronic obstructive pulmonary disease (COPD), disseminated lung diseases, pulmonary embolism (PE) and primary PH (PPH).

Study Results: In the COPD group, pulmonary artery systolic pressure (PASP) at rest was equal to or below the upper limit of normal in 42.1% of patients, ranged from 31 to 50 mm Hg in 45.7% of patients, and exceeded 50 mm Hg in only 12.2% of patients. In the group of patients with disseminated lung diseases, estimated PASP was normal in 64.5% of patients and ranged from 31 to 50 mm Hg and from 51 to 70 mm Hg in 31.3% and 3.9% of patients, respectively. Another 0.3% of patients in this group had PASP above 70 mm Hg. In the group of patients with PE these percentages were different: PASP ranged from 31 to 50 mm Hg and from 51 to 70 mm Hg in 44.0% and 38.1% of patients, respectively. Another 17.9% of patients in this group had PASP above 70 mm Hg. In all patients with PPH, PASP was above 70 mm Hg, the mean value was 89 ± 2.7 mm Hg. Mean right-ventricle ejection fraction (RV EF) did not significantly differ in patients with PPH and PE and those with COPD or disseminated lung diseases without PH but was significantly lower (p < 0.05) in patients with COPD and PH. This tendency was observed for both velocity and fractional parameters of RV as well as for parameters of diastolic function of the right heart.

Conclusion: Hemodynamic changes observed in this study correlate better with the nature of the underlying disease than with the level of pulmonary artery pressure. In the next years, an evaluation of myocardial damage induced by pulmonary pathologies based on an wide range of biochemical, immunological and genetic methods should become a major focus of investigations of chronic cor pulmonale.

Keywords: chronic obstructive pulmonary disease, pulmonary hypertension, disseminated lung diseases, chronic cor pulmonale, pulmonary embolism.

Disseminated Lung Tuberculosis: Difficult Case of Differential Diagnosis

  1. N. Makariyants, E. I. Shmeliov, L. N. Lepyokha, M. A. Bagirov, N. L. Karpina

Disseminated pulmonary diseases is a large group of entities, including sarcoidosis, tuberculosis, extrinsic allergic alveolitis, lung metastases, and others. Diagnosing is often challenging and requires that a clinician takes certain measures as part of a care algorithm and correctly interprets the results. The described clinical case demonstrates that patients need a comprehensive examination, including clinical and functional investigations, microbiology, and morphology. It highlights the importance of morphological confirmation in patients with a disseminated pulmonary disease.

Keywords: dissemination, chest computed tomography, transbronchial biopsy, bronchoalveolar lavage, tuberculin tests, acid-fast Mycobacterium, granulomatosis, sarcoidosis, disseminated tuberculosis.

Nonallergic Rhinitis with Eosinophilia: Clinical Picture and Specific Features

  1. P. Bondareva, A. I. Kryukov, T. G. Barkhina, L. M. Danilova, V. A. Utesheva

Objective of the Review: To identify the clinical and laboratory characteristics of nonallergic rhinitis with eosinophilia (NARES).

Key Points: Nonallergic rhinitis with eosinophilia is a chronic inflammatory disease affecting nasal mucosa. It is characterized by the absence of systemic atopia confirmed by laboratory data and changes in the composition of nasal secretions (an increased percentage of eosinophils to more than 20% of the total cell count in rhinocytogram), which reflect local eosinophil infiltration.

Conclusion: Since the clinical picture of NARES is similar to that of allergic rhinitis, it is important to identify clinical and diagnostic criteria of NARES and specific pathogenetic features that distinguish this condition from other forms of rhinitis. This will help improve and optimize treatment options for this disorder.

Keywords: nonallergic rhinitis, nonallergic rhinitis with eosinophilia, allergic rhinitis.

Using Diclofenac as Pain Treatment After Primary Replacement of Large Joints

  1. Yu. Khudoshin, N. A. Khudoshin, D. S. Yakushev, N. A. Aladyshev

Study Objective: To assess the use of Diclofenac as pain treatment in the postoperative period after primary replacement of large joints.

Materials and Methods: The study included 480 patients, aged 22 to 70. They were randomly divided in two groups (240 subjects in each group). In Group I, participants received Diclofenac (25 mg/mL solution) as pain treatment. It was administered as intramuscular injections at a dose of 75 mg twice a day for two days. In Group II, patients received Ketoprofen as intramuscular injections at a dose of 100 mg twice a day for two days. The pain intensity was measured using pain scores as evaluated on a 5-point scale, a visual analogue scale (VAS), and the McGill Pain Questionnaire. Clinical examination was performed before treatment and on Day 2 post-treatment.

Study Results: After treatment, a statistically significant reduction in the pain scores as evaluated on a 5-point scale and the McGill Pain Questionnaire (from 4.7 to 1.9 points and from 7.1 to 3.0 points, respectively; p ≤ 0.005 for both comparisons) as well as in the VAS pain score (from 7.8 cm to 3.1 cm; p ≤ 0.01) was seen in patients who received Diclofenac. In the Ketoprofen group, there was a statistically significant reduction in the VAS pain score (from 7.6 cm to 3.8 cm; p ≤ 0.01), the pain score on a 5-point scale (from 4.5 to 2.0 points), and the McGill pain score (from 6.9 to 3.5 points); p ≤ 0.005 for the last two comparisons. The treatment was effective in 94.1% of cases in the Diclofenac group and in 82.1% of cases in the Ketoprofen group (p ≤ 0.005).

Conclusion: Nonsteroidal anti-inflammatory drugs, particularly Diclofenac 150 mg/day, can be a reasonable option for post-surgery pain control following primary replacement of large joints. Diclofenac therapy is highly effective and is associated with a low risk of complications.

Keywords: Diclofenac, post-surgery pain, replacement of large joints.

Doctor.Ru Anesthesiology and Critical Care Medicine. Medical Rehabilitation No. 12 (129). Part I

Goal-Directed Fluid Therapy for Intraoperative Hypovolemia in Abdominal Surgery

  1. A. Smeshnoi, I. N. Pasechnik, R. R. Gubaidullin, E. I. Skobelev

Study Objective: To investigate the effects of intraoperative goal-directed therapy (GDT), guided by stroke-volume variation (SVV) monitoring, on postoperative outcomes of major gastrointestinal (GI) surgeries.

Study Design: This was a prospective randomized study.

Materials and Methods: The study included 64 patients who had undergone major abdominal surgery — an intestinal bypass procedure. In the control group (n = 32), intraoperative fluid therapy was guided by routine hemodynamic parameters; while in the experimental group (n = 32), it was administered based on data from minimally invasive hemodynamic monitoring, according to a pre-designed protocol (GDT protocol), with SVV being the key parameter.

Study Results: Complications were observed in 31.2% of patients in the experimental group, and in 59.4% of patients in the control group (p < 0.05). In both groups, the most common complications were GI events. However, in the control group, they developed twice as often (p < 0.05). In the group of patients receiving GDT, there was a trend towards a lower rate of cardiovascular events, surgery wound infection, and lower-limb deep-vein thrombosis.

Conclusion: Goal-directed therapy guided by SVV is quite a subtle tool to optimize fluid therapy in hypovolemic patients. In addition, it helps reduce the rates of postoperative complications in patients undergoing major abdominal surgery.

Keywords: goal-directed fluid therapy, stroke-volume variation, oxygen transport, fluid optimization, hypovolemia, hypervolemia.

Nutritional Support in Terms of Enhanced-Recovery-After-Surgery Approach

  1. N. Pasechnik

Objective of the Review: To provide information about nutritional support in surgery patients in terms of an enhanced-recovery-after-surgery (ERAS) approach.

Key Points: Prior to surgery, all patients should be screened for nutritional deficiencies and, if necessary, receive corrective treatment. Fasting before surgery is associated with significant metabolic changes that affect the postoperative period. Given before surgery, carbohydratecontaining drinks reduce insulin resistance and rates of complications. Early enteral nutrition, including specifically-designed products, helps restore intestinal motility and reduce mortality.

Conclusion: Nutritional support in surgery patients is an integral part of the ERAS approach. Nutritional support is only possible when many factors are taken into consideration and an effective multidisciplinary team has been put into place.

Keywords: nutritional support, enhanced recovery after surgery.

Perioperative Myocardial Protection in General Surgery Patients with Concurrent Cardiac Disorders

  1. I. Skobelev, I. N. Pasechnik, A. A. Meshcheryakov

Purpose of the Paper: To assess the potential of perioperative myocardial protection in general surgery patients with concurrent cardiac disorders.

Key Points: Surgical stress can exacerbate concurrent cardiac disorders, even when patients receive adequate anesthesia. This reaction is mainly explained by the myocardial ischemic damage caused by the impaired balance between oxygen delivery and consumption. Exogenous phosphocreatine (PC) provides antiischemic and antiarrhythmic protection. It also improves physical activity and reduces the risk of cognitive disorders.

Conclusion: In general surgery patients, PС is an effective option for perioperative prevention of cardiac and cognitive disorders.

Keywords: phosphocreatine, hemodynamics, ischemia.

Preventive Treatment with Surfactant in Thoracic Surgeries Associated with High Risk of Respiratory Failure

  1. V. Gekkieva, A. E. Bautin, V. V. Osovskikh, I. V. Tregubova , A. A. Seiliev, O. A. Rozenberg

Study Objective: To evaluate the efficacy of preventive treatment with surfactant (ST) in thoracic surgeries associated with a high risk of acute respiratory failure (ARF).

Study Design: This paper analyzes data obtained from two prospective controlled studies.

Materials and Methods: In a patient population who required early repeated thoracotomy (RT) following thoracic surgery, ST (surfactant-BL) was instilled endobronchially during RT in 37 patients (main group, MG), and was not administered to another 10 patients (control group, CG). In MG, ST was instilled into each lobar bronchus at a total single dose 6 mg/kg or 150 mg into the remaining lung after pneumonectomy. In the patient population who were undergoing reconstruction procedures on the descending thoracic aorta, 3 mg/kg of ST was instilled into the left principal bronchus in 9 patients (MG); another 9 patients (CG) did not receive ST.

Study Results: Both during RT and thoracic-aorta surgery, preventive treatment with ST was associated with a significantly faster restoration of oxygenation. Both populations showed a reduction in the rates of acute respiratory distress syndrome: 20.0% in CG and 0% in MG (p < 0.05) of patients who required RT, and 33.3% in CG and 0% in MG (p < 0.05) in those who were undergoing aorta surgery. In addition, the patient population who required RT showed a decrease in the rates of ventilator-associated pneumonia (60.0% in CG and 0% in MG, p < 0.05). In patients who required RT and thoracic-aorta surgery, preventive treatment with ST helped significantly reduce the length of mechanical ventilation and the duration of ICU treatment.

Conclusion: These studies proved the efficacy of preventive treatment with ST in patients undergoing thoracic surgeries associated with a high risk of ARF.

Keywords: repeated thoracotomy, descending thoracic aorta, surgery, postoperative respiratory failure, surfactant.

High-Technology Perioperative Antibiotic Prophylaxis in Terms of Surgery’s Fast-Track Concept

  1. V. Yakovlev

Objective of the Review: To outline the principles and tactics of perioperative antibiotic prophylaxis as it relates to the fast-track concept.

Key Points: Preventive use of antibiotics in the perioperative period is a proven tool to stop surgical-wound infection (SWI). The authors provide a rationale for the main principles behind the preventive use of antibacterial agents in surgical patients; modes of the drugs’ administration; tailored schemes of antibiotic prophylaxis in patients undergoing different surgeries; and the choice of drugs in specific clinical situations, including those where fast-track technologies are used.

Conclusion: Antibiotics administered by members of the anesthesiologists' team right before surgeries to prevent SWI help reduce the rates of complications, the need for medication treatment, and, finally, the length of ICU stay and inpatient hospitalization. All this can make the prophylactic use of antibiotics a component of the fast-track concept.

Keywords: antibiotic prophylaxis, fast track.

Antibacterial Treatment for Surgical-Wound Infection in Diabetes Patients

  1. L. Ryabov, I. N. Pasechnik

Objective of the Review: To discuss the potential of antibacterial agents in treating surgical-wound infection (SWI) in diabetes patients.

Key Points: The introduction of antibiotic prophylaxis into wide clinical practice and the constant improvement of surgical techniques do not guarantee that SWI will be prevented. In diabetes patients undergoing surgery procedures, the rates and severity of SWI are increasing. A combination approach to treating SWI includes systemic antibacterial therapy. Our data show that parenteral ceftaroline, a cephalosporin antibiotic, combined with metronidazole is a safe alternative to a combination of carbapenems and vancomycin.

Conclusion: Treating SWI in diabetes patients requires a combination approach. Systemic antibacterial treatment should be administered, keeping in mind the polymicrobial nature of surgical infections.

Keywords: surgical infection, antibacterial treatment.

Options for Enhanced Recovery After Surgery for Cancer Patients

  1. E. Khoronenko, V. M. Khomyakov, D. S. Baskakov, A. B. Ryabov, Yu. S. Donskova, A. A. Aleksin

Study Objective: To assess the efficacy and safety of an enhanced-recovery-after-surgery (ERAS) protocol in patients with gastric cancer.

Study Design: This was an open-label, retrospective study.

Materials and Methods: The study included a comparative analysis of the perioperative period in 80 patients who had undergone surgery for gastric cancer between 2013 and 2015. In the main group (n = 40), patients were followed-up using an ERAS protocol, which was introduced in January 2014. The control group was made up of 40 patients who had had surgery in 2013.

Study Results: The duration of hospital stay was 14.25 ± 1.48 days in the ERAS group and 15.5 ± 2.82 days in the control group (р = 0.0001). The length of intensive-care-unit (ICU) stay was 1.25 ± 0.44 days in the ERAS group and 1.75 ± 0.89 days in the control group (р = 0.02). Peristaltic sounds reappeared in 1.33 ± 0.47 and 1.93 ± 1.09 days in the ERAS and control groups, respectively (р = 0.02). There were three significant post-surgery complications in the ERAS group and nine in the control group (p = 0.06).

Conclusion: By optimally combining ERAS components at the preoperative and intraoperative stages, the length of stay in ICU/hospital can be shortened and the rates of postoperative complications can be reduced.

Keywords: early postoperative rehabilitation, early recovery after surgerу, gastric cancer.

Fast-Track Recovery Strategies to Treat Necrotizing Enterocolitis in Newborns

  1. N. Obedin, S. V. Minaev, A. V. Kachanov, M. V. Annenkov, E. A. Tovkan, I. N. Gerasimenko

Study Objective: To assess the effects of presacral analgesia with ropivacaine on fast-track recovery in newborns who have undergone surgery for necrotizing enterocolitis (NEC).

Study Design: This was a randomized, double-blind, controlled, prospective study.

Materials and Methods: Newborns with grade 2/3 NEC were randomly assigned to two groups that were comparable in terms of the babies' gestational age, their body weight and their sex. In Group I (n = 15), patients received a combination treatment, including presacral analgesia with ropivacaine. Group II (n = 13) received standard treatment.

During treatment, pain intensity was assessed by the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The following parameters were compared between the groups: the dose of fentanyl given during surgery, the length of mechanical ventilation, and the time to extubation after surgery. The study endpoints included the death rate and the rates of intra- and extra-abdominal complications.

Study Results: Sixteen hours after treatment initiation, CHEOPS-assessed pain levels in Group I were significantly lower than in Group II (6.0 ± 0.5 and 9.5 ± 0.3, respectively; p < 0.05). Comparing Group I to Group II, the fentanyl dose (62 ± 2.5 mcg and 120 ± 3.2 mcg, respectively), the length of mechanical ventilation (1.5 ± 0.8 days and 3.4 ± 1.1 days, respectively), and the rates of complications were significantly lower (p < 0.05 for all comparisons).

Conclusion: Presacral analgesia with ropivacaine is an effective way to accelerate the recovery of newborns with NEC, and it can bring the management of patients with this condition more in line with the fast-track strategy.

Keywords: necrotizing enterocolitis, anesthesia, ropivacaine, CHEOPS, fast track.

Doctor.Ru Anesthesiology and Critical Care Medicine. Medical Rehabilitation No. 12 (129). Part II

Programs of Medical Rehabilitation after Coronary Artery Bypass Grafting

  1. Yu. Mukharlyamov, M. G. Sychyova, M. A. Rassulova

Objective: to present recommendations for medical rehabilitation after coronary artery bypass grafting (CABG) for clinicians.

Key points. According to our data, complex cardiac rehabilitation programs that include cardio-respiratory exercise (using cyclic exercise machines and weighted static and dynamic loads) and corrective technologies (blood irradiation therapy — BIT, intravenous ozone therapy — IOT, intermittent hypoxic training — IHT) have more pronounced effect on hemodynamic, electrophysiological, regulatory, adaptation parameters and also on tolerance of exercise, ventilation to perfusion ratios, and oxygen transport in comparison to the classic rehabilitation treatment programs.

The inclusion of small power loads in the cardiac rehabilitation programs potentiated hemodynamic, adaptation and regulatory effects of BIT, IOT, and IHT and was safe for the patients because of telemetric monitoring of cardiac and respiratory system. Altogether, the classic methods of physiatrics and physical therapy had a significant effect on the clinical, hemodynamic, regulatory, and adaptation parameters.

  1. Early mobilization of the patients after thoracic surgery helps minimize lung complications, decrease muscle weakness, and accelerate the recovery. Complex programs of cardiac rehabilitation are significantly more effective than the single treatment factors. Principles of evidence-based medicine, training of qualified specialists, and introduction of the principle of legitimacy of the medical rehabilitation methods based on the approved standards, textbooks, and other sources is essential for successful rehabilitation after thoracic surgery.

Keywords: accelerated rehabilitation after surgery, Fast Track, cardiac rehabilitation, coronary artery bypass grafting.

Differentiated Approach to Rehabilitation of Patients with Myocardial Infarction during Health Resort Treatment

  1. M. Orlov, B. N. Levitan, A. V. Orlova, E. V. Petelina, N. F. Barkova

Study objective: to justify individual application of variant techniques of low-intensity light therapy within complex rehabilitation programs after myocardial infarction (MI) during health resort treatment.

Design: a comparative study.

Materials and methods. 232 patients of 47.8 ± 2.9 years old with IM were assessed. Patients of the first (main) group (n = 123) underwent complex light therapy (10 sessions of Bioptron light therapy and then 10 sessions of laser therapy). The second (control) group (n = 109) underwent 10 sessions of laser therapy per standard protocol of health resort treatment. Clinical, laboratory, and functional investigations were used for the study purposes.

  1. Bioptron light therapy and laser therapy were shown to be clinically useful within a complex rehabilitation program of IM patients during health resort treatment. 70.8% patients of the main group and 59.2% patients of the control group had restored their functional reserve after the rehabilitation activities.
  2. Variant techniques of low-intensity light therapy within complex rehabilitation programs of IM patients during health resort treatment ensure optimal therapeutic effect by increasing tolerance of exercise and restoring the decreased functional reserves of the cardiovascular system.

Keywords: myocardial infarction, rehabilitation, laser therapy, Bioptron Light Therapy system, adaptive response of the body, functional reserves of the cardiovascular system.

Main Parameters of the Rehabilitation Prognosis in Stroke Patients

  1. N. Razumov, E. A. Melnikova

Study objective: to define objective parameters for assessment of rehabilitation prognosis in patients with acute cerebrovascular events (ACVE).

Design: a prospective study.

Materials and methods. An extensive analysis of clinical and instrumental investigation data of 203 stroke patients was conducted. Data of 133 patients (65.5%) with hemispheric ischemic stroke, 40 (19.7%) with brainstem ischemic stroke, and 30 (1.8%) with hemispheric intracerebral hematoma were analyzed.

  1. This is the first time when rehabilitation subgroups of patients with ACVE were defined by the main risk factors. The significance of each risk factor for the patients with ischemic and hemorrhagic stroke was ranked. Factors that influence recovery of such patients significantly during rehabilitation were described: age, presence or absence of chronic pain, education level, date and type of stroke, place and spread of the lesion, scope of the focal changes, cerebral atrophy, leukoaraiosis, presence and degree of stenosis in the internal carotid artery circulation contra- and ipsilateral to the lesion, history of surgeries of the main head arteries, abnormal focal electroencephalographic findings, presence or absence of perifocal brain edema associated with displacement of medial structures during the acute stroke phase, and the number of the strokes.
  2. Selection of rehabilitation subgroups allows differentiating approach to the assessment of recovery prognosis after stroke.

Keywords: post stroke rehabilitation, risk factors, rehabilitation potential, rehabilitation prognosis, psychomotor functions.

Spasticity and Pain Syndromes after Stroke in Clinical Practice

  1. O. Amanova, V. V. Kovalchuk, T. I. Minnullin, L. E. Kanteeva

Objective: to describe principles and rules of management of post-stroke patients with increased muscle tone and pain syndromes.

Key points. The article describes principles and risk factors of these stroke complications. The main spasticity patterns in post-stroke patients and the relevant rehabilitation goals are described. Various physical and medication methods and rehabilitation tools for this patient category are presented. Special aspects of physical therapy and its main techniques for this pathology are reviewed, such as proprioceptive neuromuscular facilitation and Bobath concept. Diagnostics and treatment of main pain syndromes in post-stroke patients are considered.

  1. Adequate management of post-stroke patients with increased muscle tone and pain syndromes is a major component of combined therapy of these patients and requires adherence to certain rules and principles. Relieving pain and spasticity after stroke is one of the essential conditions of increasing efficacy of the rehabilitation, degree of the patient’s functional recovery, level of their social and personal adjustment, and improvement of the quality of life.

Keywords: stroke, rehabilitation, spasticity, pain.

Restoration of Functional Activity of Upper Limb after Cerebral Stroke

  1. P. Yastrebtseva, S. V. Nikolaeva, E. A. Baklushina

Objective: to analyze the efficacy of contemporary methods of rehabilitation after stroke based on the Russian and foreign scientific publications.

Key points. The most practical recommendations for restoration of the upper limb function are the limitation-induced therapy, psychoneurological correction, mechanotherapy (including the use of robotic technologies) and functional electric stimulation. Evidence about electromyography with biological feedback, virtual reality method, and bilateral training is insufficient.

  1. Before recommending any procedure, the medical team should consider its usefulness based on the procedure efficacy, type of the motor defect, potential risks and complications, and the patient’s preferences.

Keywords: rehabilitation, stroke, recovery, upper limb, recommendations, methods of rehabilitation, conclusiveness.

Efficacy of Active Medical Rehabilitation in Patients with Trauma-Related Spine Conditions

  1. A. Bodrova, E. I. Aukhadeev, R. A. Yakupov, A. D. Zakamyrdina

Objective: to evaluate efficacy of active medical rehabilitation with the use of biofeedback (BFB) under electromyography (EMG) in patients with trauma-related spine conditions (TRSC).

Design: randomized study.

Materials and methods. 212 patients (39 women and 173 men) with TRSC of 32.3 ± 10.7 years of age were examined. They had the trauma from 1,5 to 6 years ago. The main group (n = 103) received standard treatment with active-passive electrical stimulation and active mechanotherapy with BDB under EMG, and gait training on a telescopic patient lift. The control group (n = 109) received standard therapy, electromyostimulation, and passive mechanotherapy without BFB. Level and severity of the traumatic spinal cord injury were described according to the classification developed by American Spinal Cord Injury Association. Patient activity and involvement in everyday and social life was assessed with the Functional Independence Measure and modified functional rating scale of activity and quality of life.

  1. The level of self-service and independence in everyday life increased by 36.4% in patients with cervical injury (p < 0.001), by 55.6% in patients with thoracic injury (p < 0.001), and by 71.4% in patients with lumbosacral injury (p < 0.001) after the course of active medical rehabilitation in the main group of patients with TRSC with severe and absolute disorders of activity and involvement according the International Classification of Functioning, Disability, and Health (ICF). No statistically significant changes were seen in the control group after the rehabilitation.
  2. Active medical rehabilitation with BFB under EMG increases efficacy of rehabilitation of patients with TRSC with injury at different levels of the spinal cord.

Keywords: trauma-related spine condition, efficacy of medical rehabilitation, biofeedback, mechanotherapy with biofeedback under electromyography.

Vector-Based Assessment of Rehabilitation Potential

  1. D. Bolotov, V. E. Yudin, M. V. Turlay, S. M. Starikov

Objective: to present the system for assessment of rehabilitation potential developed by the authors.

Key points. Rehabilitation is a complex of concurrent and complementary medical, professional, and social activities that can be pictured as rehabilitation vectors (aspects of the rehabilitation program) with numerical ratings.

The general rehabilitation vector is the sum of the specific rehabilitation vectors, i.e. sum of the numerical ratings of various capabilities of the body.

  1. The developed system allows assessment of the potential implementation of the rehabilitation vectors at the present moment and in the short and long-term perspective.

Key words: rehabilitation potential, degree of functional insufficiency.

Modern Technologies for Medical Rehabilitation of Children with Atopic Dermatitis

  1. V. Pogonchenkova, M. A. Rassulova, M. A. Khan, N. A. Lyan, T. A. Filatova, I. A. Bokova

Objective of the review: to present modern technologies for medical rehabilitation of children with atopic dermatitis.

Key points. High significance has been attached lately to the drug-free treatment of atopic dermatitis because of the high frequency of adverse effects of the medications. Main goals of the medical rehabilitation in atopic dermatitis are to normalize state of the central nervous system and autonomic nervous system and to provide hyposensitization, sedative, antitoxic, anti-inflammatory, reabsorbing, trophic, antipruritic, and health promoting effects.

  1. Drug-free treatment technologies are used at all steps of medical rehabilitation of children with atopic dermatitis.

Keywords: children, medical rehabilitation, atopic dermatitis, physiatrics.

Ecological and Anthropological Concepts of Rehabilitation of the Disabled and Restoration of Human Health

  1. I. Aukhadeev, R. A. Bodrova, Kh. V. Iksanov

Objective: to review concepts that describe complex relationships between people, including the disabled ones, and the environment.

Key points. Preservation of the natural environment and elimination of ecological consequences were set as strategic goals for assurance of ecological safety and rational use of natural resources in Russia. The International Classification of Functioning, Disability and Health considers health in the context of internal and external factors and thereby encourages development of methodological views on the health restoration in ecological and anthropological aspects. This publication contains data on the environmental factors that lead to morbidity and disability both in adults and children. Concepts of interactions between nature and culture in ecological anthropology are described.

  1. The data presented in this publication promote the full development of complex programs for rehabilitation of the disabled and prevention of disability.

Keywords: ecological anthropology, autecology, demecology, synecology, ethnic ecology.

Accelerated Recovery Program: Roles of the Surgeon and the Anesthesiologist/Resuscitation Specialist — Independence or Team-Based Approach?

  1. N. Pasechnik, G. N. Khrykov, A. D. Khalikov, P. S. Salnikov, G. I. Mityagin

Objective: to evaluate the efficiency of implementation of the accelerated recovery program (ARP) with independent and team work of the surgeon and the anesthesiologist/resuscitation specialist.

Key points. Peri-operational management of the patients, including the nutritional preparation for the surgery, adequate myorelaxation during the surgery, and postoperative pain management, should be agreed by the surgeon and the anesthesiologist/resuscitation specialist together. A mutually agreed concept minimizes surgical stress and optimizes treatment results.

  1. A multidisciplinary team helps prevent fragmentation of the treatment process and elaborate effective approaches to the treatment of surgical patients.

Keywords: accelerated recovery program, surgeon, anesthesiologist, surgical stress, neuromuscular blockade.

Accessible Environment in Hospital Setting: Legal Framework, Potential Ways of Implementation

  1. R. Makarova, D. V. Shutov

Objective: to review Russian regulatory documents and other open sources that describe valid ways and methods of creating an accessible environment for patients who spend some time in a hospital setting.

Key points. Use of medical devices, rehabilitation tools and technologies as well as educating the patients and their caregivers on self-service technologies and home adaptation are reviewed from the perspective of integrating low-mobility and post-operative patients in the active living. We stress the importance of the employment of health care practitioners and the establishment of conditions for medical rehabilitation as factors of accessible environments that provide maximum freedom of movement and physiological functioning of the patients in the hospital setting.

  1. Integrated development of accessible environment not only guarantees safe and comfort stay in the hospital for the patient and promotes earlier activation and adaptation for transfer to the outpatient setting but also ensures the maximal preservation of working capacity of highly qualified health care practitioners and increases the efficiency of the medical organization.

Keywords: accessible environment, inpatient setting, people with limited mobility, regulatory aspects, rehabilitation.