卷 86, 编号 4 (2014)
- 年: 2014
- 文章: 21
- URL: https://journals.rcsi.science/0040-3660/issue/view/1786
Editorial article
Clinical diagnosis progress and continuing medical education
摘要
The paper discusses current approaches to diagnosing in an internal medicine clinic and to improving diagnostic tactics. It gives prospects for training physicians in current diagnostic approaches in the framework of the continuing medical education system.
Terapevticheskii arkhiv. 2014;86(4):4-7
4-7
Prognostic value of detection of arterial hypotensive episodes in patients with chronic heart failure
摘要
AIM: To define the prognostic value of arterial hypotension (AH) episodes in patients with chronic heart failure (CHF)/MATERIAL AND METHODS: One hundred and ninety-nine patients (mean age 57.2±10.5 years) were examined. Functional Class I, II, III, and IV CHF was diagnosed in 24, 92, 82, and 1 patients, respectively. The cause of CHF was coronary heart disease concurrent with hypertensive disease in 160 patients. AH was diagnosed when their blood pressure (BP) was ≤100/60 mm Hg during medical visits and daytime BP ≤100/60 mm Hg and nocturnal BP ≤85/47 mm Hg were measured during 24-hour BP monitoring (BPM). The follow-up lasted 24 months. The major end-point was a combined measure of death rates from any cause, incidence rates of myocardial infarction (MI) or stroke/RESULTS: AH was identified in 6.5% of the patients with CHF when BP was measured during their medical visit; 24-hour BPM revealed hypotensive episodes in 65.8%. There were no differences in the major endpoint in relation to the presence of AH episodes. MI developed only in patients with systolic AH episodes (5 versus 0 patients; ξ2=5.55; р=0.02) and the risk of MI was associated with the greater magnitude of diastolic AH/CONCLUSION: 24-hour BPM can substantially increase the detection rate of potentially dangerous BP changes. Almost three fourths of patients with CHF were observed to have AH episodes during a day. The use of angiotensin-converting enzyme (ACE) inhibitor/diuretic, ACE inhibitor/mineralcorticoid receptor antagonist, ACE inhibitor/nitrate combinations in the treatment of patients with CHF increase the risk of transient AH. In patients with CHF, the risk of MI is associated with the detection of systolic AH episodes and the magnitude of diastolic AH.
Terapevticheskii arkhiv. 2014;86(4):8-12
8-12
A poor outcome prediction scale in ST-segment elevation myocardial infarction patients undergoing emergency percutaneous coronary intervention
摘要
AIM: To make a prediction scale using a set of clinical and laboratory prognostic variables for patients with ST-segment elevation myocardial infarction (STEMI) on their electrocardiograms (ECG) who have undergone percutaneous coronary intervention/MATERIAL AND METHODS: The study enrolled 154 STEMI patients who had undergone percutaneous coronary angioplasty with stenting of the artery supplying blood to the area of an ischemia. Enzyme immunoassay was used to determine the levels of cytokines and selectins on days 1 and 10/RESULTS: During a year, the authors identified the following independent risk factors of a poor outcome (PO): symptoms of Killip Class III-IV heart failure; a history of smoking; rhythm and conduction disturbances on day 1 of the disease; tumor necrosis factor-α levels determined on day 1 of the disease; IL-1α and sP-selectin levels measured on day 10. In the made prediction scale, a score was assigned to each independent prognostic variable to estimate the risk of PO. The borderline values of summing the scores, which divided the patients into groups at low, moderate, and high risk for PO, were determined for the practical application of the scale, by using the receiver operating characteristic curve (ROC) analysis. The performance of the model was tested using an independent sample of STEMI patients (n=50). The probability that the classification of the model was correct amounted to 89.6% (p<0.0001)/CONCLUSION: The made prediction scale allows the patients with STEMI to be allocated to groups at low, moderate, high risks for PO during a year. Evaluation of the prognostic efficiency of the new scale versus the known scales PAMI, CADILLAC, and TIMI ST elevation, by plotting the ROC curve and estimating the area under the latter, demonstrated the high predictive ability of the new scale.
Terapevticheskii arkhiv. 2014;86(4):13-18
13-18
Analysis of genotypes combinations at the polymorphic points of the promoter regions of the genes of three matrix metalloproteinases and the gene of vascular endothelial growth factor (VEGF) in patients with prior acute myocardial infarction
摘要
AIM: To analyze the association of the promoter polymorphism of the genes of the matrix metalloproteinases (MMP) MMP2 (–1306), MMP3 (–1171), and MMP9 (–1562) and two vascular endothelial growth factor (VEGF) gene regulatory regions (–2578, +936) with the development of myocardial infarction (MI). Materials and methods. DNA was analyzed in 251 patients with a history of MI. Five polymorphic positions were genotyped by restrictase analysis of amplification products, by using specific primers/RESULTS: In addition to the MMP3 5A5A monogenotype, there were 4 complex genotypes that were significantly different between two analyzed groups and positively associated with acute coronary syndrome. Among them, each of two genotypes included 2 polymorphic positions; two genotypes did 3 analyzed polymorphic positions. Four complex (two-locus (n=1), three-locus (n=2), four-locus (n=1) genotypes that were negatively associated with MI were also identified./CONCLUSION: These findings are evidence in favor of our assumption that the increasing number of genotypes as part of the analyzed combined genetic complexes detectable in one patient considerably enhances the clinical significance of the results of immunogenetic analysis.
Terapevticheskii arkhiv. 2014;86(4):19-24
19-24
Problems in the diagnosis of acute kidney injury in patients with ST-segment elevation myocardial infarction
摘要
AIM: To estimate the frequency and severity of acute kidney injury (AKI) in patients with ST-segment elevation acute myocardial infarction (STSEAMI), to specify whether the changes in diuresis and serum creatinine levels are equally sensitive diagnostic criteria for AKI, and to define their prognostic value/MATERIAL AND METHODS: Three hundred and nineteen patients (249 (78%) men and 70 (22%) women; age 58±10 years) with STSEAMI who received thrombolytic therapy (TLT) were examined. The diagnosis of STSEAMI, indications for and contraindications to TLT, evaluation of its efficiency were made in accordance with the All-Russian Scientific Society of Cardiology guidelines (2007). AKI was diagnosed and classified using the KDIGO guidelines (2012)/RESULTS: AKI was diagnosed in terms of diuresis, calculated creatinine levels, and creatinine level changes in 107 (34%), 73 (23%), and 68 (22%) patients, respectively. Among the patients with AKI diagnosed in view of diuresis, in-hospital death rates were higher than in those without AKI (ξ2=25.46; p<0.001); the similar pattern was seen in patients with AKI diagnosed in terms of calculated creatinine levels (ξ2=3.99; p=0.045). Logistic regression analysis indicated that regardless of gender, age, and time interval between onset of clinical manifestation and hospital admission, the in-hospital death rates were associated with the presence of AKI in view of diuresis (relative risk 14; 95% confidence interval, 4.03 to 52.08; p<0.001)/CONCLUSION: The STSEAMI patents receiving TLT exhibited a high rate of AKI. The major problem in the early detection of AKI is associated with difficulties in the differential diagnosis of AKI and chronic kidney disease. AKI diagnosed in view of diuresis is of greater prognostic value for in-hospital mortality than that diagnosed in terms of creatinine levels. The diagnosis of renal dysfunction in view of basal creatinine levels is prognostically important despite the fact that this cannot differentiate AKI from chronic kidney disease in the early stage.
Terapevticheskii arkhiv. 2014;86(4):25-29
25-29
Use of meldonium in the combination treatment of patients with heart failure in the early post-infarction period
摘要
AIM: To evaluate the impact of 10-14-day intravenous administration of meldonium as part of combination therapy in patients with chronic heart failure in the early post-infarction period on the recovery period, structural and functional parameters, and heart rate variability (HRV)/MATERIAL AND METHODS: The investigation enrolled 60 patients (men and women) aged 45 to 75 years at weeks 3-4 after post-myocardial infarction with symptoms of Functional Class II-III heart failure. All the patients underwent 24-hour electrochocardiography monitoring, cardiac echocardiography, and HRV study. After dividing the patients into 2 groups, Group 1 (a study group) (n=30) was given intravenous meldonium (idrinol) 1000 mg/day in addition to the basic therapy of coronary heart disease. The patients in the study and control (Group 2; n=30) groups were at baseline matched for age, gender, disease severity, and basic therapy pattern/RESULTS: Following 10-14 days of treatment, both groups showed clinical improvement and the favorable changes in cardiac structural and functional parameters and HRV values, which were more pronounced in the patients receiving meldonium/CONCLUSION: The patients with CHF using meldonium as part of combination therapy in the early post-infarction period were observed to have clinical improvement, a significant reduction in the rate of angina attacks and in the need for nitrates, a decrease in the number of arrhythmic and ischemic episodes, and favorable changes in cardiac structural and functional parameters and HRV values.
Terapevticheskii arkhiv. 2014;86(4):30-35
30-35
Significance of the morphogenetic proteins FGF-23 and Klotho as predictors of prognosis of chronic kidney disease
摘要
AIM: To study the role of the morphogenetic proteins FGF-23 and Klotho in the progression of chronic kidney disease (CKD) and in the development of cardiovascular events, inflammation, protein-energy deficiency, and other complications/MATERIAL AND METHODS: Examinations were made in 70 patients with Stages I-VD CKD: 41 with chronic glomerulonephritis (including 10 with nephritis in the presence of diffuse connective tissue diseases), 22 with tubulointerstitial nephritis, and 7 with hypertensive nephrosclerosis. There were a total of 30 men and 40 women whose age was 20 to 84 years; the mean age at the study inclusion was 41±6.7 years. The serum levels of FGF-23 (Human FGF-23 ELISA kit using monoclonal antibodies to complete molecule of FGF-23) and Klotho (Human alpha-K1 ELISA using anti-Klotho antibodies) were investigated in all the 70 patients with CKD/RESULTS: The sera of all the examinees with CKD showed elevated FGF-23 and decreased Klotho levels, the magnitude of a change in which increased from Stage I to VD. In patients with different stages of CKD, the increase in FGF-23 levels, as glomerular filtration rate reduced, outstripped that in the serum levels of phosphorus and intact parathyroid hormone. There was a strong correlation of the serum level of the morphogenetic proteins, Klotho in particular, with proteinuria, C-reactive protein level, protein-energy deficiency, indicating the pleiotropic effects of these proteins. There was also a strong correlation between serum Klotho and ferritin levels and transferrin saturation percentage, which suggests that Klotho may be involved in iron regulation/CONCLUSION: The results of the investigation lend credence to the experimental and clinical findings that the serum levels of the morphogenetic proteins FGF-23 (an increase) and Klotho (a decrease) are early markers for progressive CKD and that their changes begin just in Stage III CKD and progress as renal failure worsens.
Terapevticheskii arkhiv. 2014;86(4):36-44
36-44
Endothelial dysfunction gene polymorphisms and the rate of liver fibrosis in chronic hepatitis C
摘要
AIM: To assess the association of the CYBA, NOS3, and MTHFR gene polymorphisms and a rate of fibrosis progression in chronic hepatitis C (CHC)/MATERIAL AND METHODS: One hundred and nine CHC patients with the verified stage of liver fibrosis and cirrhosis at its onset were examined. The disease duration was determined in all the patients and additional risk factors of liver lesion were absent. A group of rapidly progressive fibrosis comprised 55 patients with a calculated fibrosis progression rate of 0.130 fibrosis units/year or higher and 54 patients with a progression rate of less than 0.130 fibrosis units/year were assigned to a slow fibrosis group. A compression group consisted of 299 healthy blood donors. The polymorphism of the genes under study was determined by polymerase chain reaction-restriction fragment length polymorphism analysis/RESULTS: The mutant TT genotype of the CYBA gene was significantly more common in the CHC patients with rapidly progressive fibrosis than in those with slowly progressive fibrosis (odds ratio for TT 9.09 at 95% confidence interval, 1.09 to 74.83; p=0.0161). No significant differences were found in the distribution of the alleles and genotypes of the NOS3 and MTHFR genes between the groups of patients with slowly and rapidly progressive fibrosis/CONCLUSION: The findings make it possible to regard the TT genotype of the CYBA gene from the C242T locus as profibrogenic and as one of the markers of the poor course of CHC.
Terapevticheskii arkhiv. 2014;86(4):45-51
45-51
Tactics for the correction of enteric microbiocenotic abnormalities in the combination therapy of patients with chronic liver diseases
摘要
AIM: To evaluate the efficacy of the symbiotic Linex used in the combination therapy of liver cirrhosis (LC)/MATERIAL AND METHODS: Seventy-four patients with LC, including 44 who received additionally the symbiotic Linex and 30 who had conventional therapy, were examined. All the patients underwent clinical and biochemical blood tests, abdominal ultrasonography, fecal test for bacteria, gas chromatography-mass spectrometry of the blood composition of microbial markers, number connecting test, and quality-of-life assessment (SF-36)/RESULTS: The symbiotic-treated patients showed a significant improvement in biochemical parameters (decreases in transaminase activities, bilirubin levels, hepatic protein-synthetic function - there were elevations in the concentrations of total protein from 74.0±0.50 to 78.1±0.80 g/l (p<0.05) and albumin from 30.6±1.7 to 35.5±1.6 g/l (р<0.05). There were also increases in the count of bifidobacteria from 8.7±0.1 to 9.1±0.1 lg CFU/g (р<0.05), lactobacilli from 5.0±0.2 to 5.2±0.2 lg CFU/g (р<0.05) and in the total count of Escherichia coli from 7.6±0.3 to 7.9±0.3 lg CFU/g (р<0.05); a tendency for normalization of microbial markers was revealed by mass spectrometry; the manifestations of hepatic encephalopathy were alleviated (the number connecting test showed a reduction from 51.0±3.58 to 29.7±4.10 sec (p<0.05)), and the quality of life improved/CONCLUSION: By normalizing enteric microbiocenosis, the symbiotic Linex positively affects the course and prognosis of LC and it is both a symptomatic and pathogenetic agent for the treatment of patients.
Terapevticheskii arkhiv. 2014;86(4):52-57
52-57
Role of platelets in the pathogenesis of Coxiella infection
摘要
AIM: To determine the relationship of hemostatic disorders to the direct impact of Coxiella burnetii on platelets as one of the key mechanisms of the pathogenesis of Q fever./MATERIAL AND METHODS: Platelet functional activity, plasma hemostatic parameters, von Willibrand factor (vWF) were investigated; and polymerase chain reaction assay was used to determine C. burnetii DNA in the leukocyte and platelet sediments of 41 patients aged 39.9±0.8 years diagnosed with Q fever at the Astrakhan Regional Clinical Hospital in 2009 to 2010/RESULTS: The examinees were recorded to have hemorrhagic phenomena (34.7%) as a hematoma (27.2%), gingival (2.4%) and nasal (9.2%) hemorrhages, vomiting blood streaks (3.4%), melena (4.5%), roseolous-papular (22.1%) and hemorrhagic (9.3%) rashes on the skin. Examination of hemostasis revealed thrombocytopenia and platelet hypoaggregation, increased plasma fibrinogen homeostasis, and significantly elevated vWF during convalescence. C. burnetii genomic DNA was isolated from platelets in all the examinees, from leukocytes and platelets in 78% of cases and only from platelets in 22%. A fluorescence signal indicating the pathogen genome was more early recorded in 54.8% of cases in the platelets than in the leukocytes/CONCLUSION: At week 1 of the disease, the absence of significant plasma hemostatic changes and the retention of the control level vWF with the lower count of platelets and their aggregatory activity suggest that the platelets are able to interact with this pathogen, which is confirmed by the results of genodiagnosis of this rickettsiosis with the pathogens being isolated from the platelet sediment. The determination of platelet aggregatory activity is a primary diagnostic test to detect disorders in the hemostatic system. The higher detection rate of C. burnetii genomic DNA from the platelets than from the leukocyte sediment can recommend that platelets be used as biological material in the diagnosis of Q fever.
Terapevticheskii arkhiv. 2014;86(4):58-63
58-63
Impact of pharmacogenetic testing on the risk of bleedings and excessive hypocoagulation episodes in the use of warfarin: The first meta-analysis of Russian prospective studies
摘要
AIM: To perform a meta-analysis of Russian prospective studies comparing the pharmacogenetic versus conventional warfarin dosing procedures. Materials and methods. Publications were sought in the PubMed and eLibrary through September 30, 2013. Seven prospective studies comparing the pharmacogenetic method of warfarin dosing with consideration for CYP2C9, VKORC1, and CYP4F2 gene polymorphisms with the conventional one were selected. The number of minor and major bleedings and hypocoagulation episodes was taken into account. The meta-analysis was performed using MIX Pro 2.0/RESULTS: Six studies compared the number of bleedings in experimental and control groups. Analysis of statistical heterogeneity showed that extraneous factors did not influence the results of meta-analysis. The pharmacogenetic approach decreases the risk of bleeding. The pooled odds ratio (OR) was significant for minor (OR=0.49; 95% confidence interval (CI), 0.31 to 0.78; p=0.002), major (OR=0.07; 95% CI, 0.008 to 0.54; p=0.01) and both minor and major bleedings (OR=0.49; 95% CI, 0.31 to 0.78; p=0.002). Six studies estimated the number of hypocoagulation cases. There was no evidence for statistical heterogeneity (Q-test p=0.13; I2=40%). Four studies showed a group difference in the number of hypocoagulation cases (p<0.05). The pooled OR was 0.21 (95% CI, 0.15 to 0.3; p<0.01). The pharmacogenetic dosing groups had fewer hypocoagulation episodes than the control ones./CONCLUSION: The pharmacogenetic approach decreases the risk of bleeding and the episodes of hypocoagulation. The performed meta-analysis covered only two randomized trials. Improving the metalogic quality and statistical power of Russian studies will be able to get more reliable data on the impact of pharmacogenetic testing on clinical outcomes during warfarin therapy.
Terapevticheskii arkhiv. 2014;86(4):64-71
64-71
A case of diagnosis of asymmetric apical hypertrophic cardiomyopathy of the left ventricle with intraventricular obstruction
摘要
The paper describes a case of diagnosis of one of the rare forms of myocardial hypertrophy - asymmetric hypertrophic cardiomyopathy with isolated hypertrophy of the cardiac apex (an apical form) and intraventricular obstruction. It discusses problems in the diagnosis of rare forms of hypertrophic cardiomyopathy.
Terapevticheskii arkhiv. 2014;86(4):72-74
72-74
A clinical case of diagnosis of left ventricular noncompaction myocardium in a patient with infectious myocarditis
摘要
The paper describes a rare clinical case involving primary cardiomyopathy (noncompaction of the left ventricular myocardium (NCLVM), infectious myocarditis, and, possibly, hypertrophic cardiomyopathy (HCM). Objective, laboratory instrumental, invasive examination (coronarography with right ventricular endomyocardial biopsy) of the patient and histological study of his heart biopsy revealed acute infectious myocarditis concurrent with NCLVM and, possibly, HCM. The detection of a rare abnormality as NCLVM necessitates a meticulous additional examination to identify other primary cardiomyopathies (including HCM).
Terapevticheskii arkhiv. 2014;86(4):75-79
75-79
Wilson-Konovalov disease in 3 sisters: A radical change in prognosis if timely diagnosed
摘要
Wilson-Konovalov disease is a rare autosomal recessive genetic disorder in which copper accumulates in the liver, brain and other target organs. The paper describes a family case of the abdominal form of the disease in three sisters, the eldest of them died from fulminant liver failure at the age of 18 years. The second sister aged 16 years was diagnosed as having the disease at the stage of decompensated liver cirrhosis; her treatment with D-penicillamine resulted in complete disease remission. The youngest sister was diagnosed with the disease at the preclinical stage, which could expect its good prognosis. However, the patient’s refusal of treatment led to death from liver failure. This case demonstrates the importance of timely diagnosis and the possibility of dramatic improvement in prognosis even at the stage of decompensated liver cirrhosis.
Terapevticheskii arkhiv. 2014;86(4):80-84
80-84
Itching: Differential diagnosis and therapy
摘要
The lecture deals with the differential diagnosis and treatment of diseases accompanied by itching. It considers the major components of its pathogenesis, which are important to provide a rationale for its therapy. Particular emphasis is laid on the analysis of the most common classifications of the causes of itching, which take into account both pathogenetic and clinical parameters. The main differentially diagnostic signs of dermal and nondermal diseases attended by itching are given. Antihistamines among the agents intended for itching therapy are considered in detail. The efficacy and safety of first- and second-generation antihistamines, including quinuclidine derivatives, are comparatively analyzed.
Terapevticheskii arkhiv. 2014;86(4):85-90
85-90
Role of the determination of aortic pressure and rigidity aortic in patients with cardiovascular diseases
摘要
The paper reviews the literature on studies of the structural and functional properties of great arteries in patients with cardiovascular diseases. It analyses the pathophysiological components of the formation of central blood pressure (BP) and describes current registration procedures. The negative aspects of the impact of elevated central BP on target organs are considered. The prognostic and clinical values of the indicators of central arterial stiffness are demonstrated.
Terapevticheskii arkhiv. 2014;86(4):91-95
91-95
Evolution of ideas on the assessment of cardiovascular risks in the perioperative period
摘要
Substantial advance has been made in operative surgery and anesthesiology; on the one hand, population ageing and, on the other, increasing surgical care needs make the prediction of perioperative complications an important component of the entire current model of surgical care. In the last decades, the concept of risk in perioperative medicine has been formulated; the theoretical base for a statistical description of the risk concept has been created, and different integral risk prediction models based on the risk index obtained by regression analysis have been elaborated and promoted. At the same time, none of the created models can reliably assess the risk of cardiovascular events associated with surgical intervention and predict the probability of poor clinical outcomes with a high degree of accuracy.
Terapevticheskii arkhiv. 2014;86(4):96-102
96-102
Dabigatran in the prevention of stroke in nonvalvular atrial fibrillation: Complex clinical situations and real clinical practice
摘要
It is well known that there is a 5-fold increase in the incidence of strokes and systemic thromboembolic events in atrial fibrillation (AF) and anticoagulant therapy considerably reduces the risk of their development. Until recently, warfarin has been mainly used for this purpose. Dabigatran is the first representative of new-generation oral anticoagulants from a class of direct thrombin inhibitors to treat nonvalvular AF. Unlike warfarin, the drug provides a predictable and steady-state anticoagulant effect. This review presents the main pharmacological characteristics of dabigatran, the possibilities of its use in complex clinical situations in patients with AF in cardioversion, ablation, surgical/invasive interventions, hemorrhage, myocardial infarction, and stroke, as well as data on the use of the drug in real clinical practice.
Terapevticheskii arkhiv. 2014;86(4):103-107
103-107
Alcoholic liver disease: State-of-the-art
摘要
The literature review gives the present views of the diagnosis and treatment of alcoholic liver disease (ALD) and data on the genetic markers associated with the development of ALD and alcohol addiction. It discusses in detail the mechanisms of liver damage within the disease in question and substantiates indications for the use of prednisolone and pentoxifylline in alcoholic hepatitis. Therapeutic approaches to treating different forms of ALD are considered.
Terapevticheskii arkhiv. 2014;86(4):108-116
108-116
Current views on the role of probiotics in the prevention and treatment of different diseases: Focus on Linex
摘要
The paper gives documentary information on the role of probiotics in the therapy of different diseases and recommendations for their use. The efficacy and safety of the combined probiotic Linex are discussed on the basis of the results of clinical trials.
Terapevticheskii arkhiv. 2014;86(4):117-124
117-124
Antibacterial therapy for acute cystitis in the age of growing pathogen resistance
摘要
Acute cystitis refers to uncomplicated lower urinary tract infections, with the recurrence rates after the first cystitis episode being 50%. The basic treatment for the above diseases is antibacterial therapy, whose efficiency depends entirely on the right choice of a drug during initial empiric therapy. The paper gives the European Association of Urology guidelines and Russian guidelines, which are based on the results of both international (ARESC) and Russian (DARMIS) studies of urinary tract infection pathogens and their susceptibility to antibacterial drugs. Phosphomycin trometamol and furasidine potassium are the drugs of choice to treat acute cystitis in Russia now.
Terapevticheskii arkhiv. 2014;86(4):125-129
125-129