Vol 21, No 12 (2019)
Articles
THYROIDITIS. GUIDELINES (TO HELP A PRACTITIONER)
Abstract
Among endocrine disorders thyroid disorders take second place after diabetes mellitus. The World Health Organization pronounced XXI century a century of autoimmune disorders. Incidence of autoimmune disorders doubles every 5-10 years and a tendency to thyroid autoimmune disorders incidence increase is observed. In the guidelines questions of etiology, pathogenesis, clinical presentation, and diagnostics of thyroiditis are discussed. Special focus is made on treatment of these disorders for healthcare quality improvement.
Consilium Medicum. 2019;21(12):10-22
10-22
NODULAR GOITER
Abstract
The guidelines “Nodular goiter” present the key points of epidemiology and pathogenesis, modern diagnostic concept of diagnosis and differential diagnosis of various morphological variants of thyroid nodules. Standardized classifications of nodular goiter ultrasound and cytological diagnosis are demonstrated. Methods of radical treatment optimization are discussed. Guidelines are supplemented with supporting material and algorithm of diagnosis and treatment of these patients. Recommended for endocrinologists, ultrasound medical specialists, clinical laboratory medicine specialists, radiologists, surgeons, and general practitioners use.
Consilium Medicum. 2019;21(12):23-30
23-30
LABORATORY DIAGNOSIS OF THYROID NEOPLASMS
Abstract
The guideline describes in detail all the basic methods of modern laboratory diagnosis of thyroid neoplasms. Significant changes in the diagnostic concept are discussed and the updated histological classification of thyroid neoplasms and the Bethesda cytological classification are analyzed. New technologies and promising areas of the laboratory service for the differential diagnosis of benign and malignant thyroid tumors are also considered. The guideline provides examples of cytological and histological diagnosis of various neoplasms of the thyroid gland, including rare forms of tumors. The guideline is intended for use by endocrinologists, specialists in clinical laboratory diagnostics, pathologists and general practitioners.
Consilium Medicum. 2019;21(12):31-47
31-47
OBESITY (ESSENTIAL LABORATORY DIAGNOSTIC TESTS). GUIDELINES FOR GENERAL MEDICAL PRACTITIONERS
Abstract
Obesity is a chronic disease associated with an excessive fat accumulation in the body. The increasing prevalence of obesity and developing of its comorbid diseases dictate the need for a precise diagnosis based on disease history, physical and laboratory-instrumental examinations.
Consilium Medicum. 2019;21(12):48-50
48-50
PREDIABETES, MODERN VIEW ON RISK FACTORS AND TYPE 2 DIABETES MELLITUS PREVENTION (BASED ON “HUMAN AND MEDICATION” CONGRESS MATERIALS)
Abstract
Prediabetes is a condition that precedes development of type 2 diabetes mellitus (DM). In this condition glycemic ranges are between normal values and type 2 DM values. The incidence of prediabetes possibly exceeds 20%. Main risk factors of prediabetes include obesity, arterial hypertension, and lipid metabolism disorders. At present screening algorithms for prediabetes in individuals with risk factors are developed. Prevention of prediabetes progression in type 2 DM includes mandatory lifestyle changes (diet focused on weight loss and physical activity) and medical therapy in some patients.
Consilium Medicum. 2019;21(12):51-54
51-54
THE ROLE OF GLYCEMIA SELF-CONTROL IN DECREASE OF THE RISK OF DIABETIC MICROAND MACROANGIOPATHIES? BEST PRACTICE
Abstract
Combination of traditional cardiovascular risk factors with specific risk factors of early development and quick progression of atherosclerosis including first of all hyperglycemia is typical in patients with diabetes mellitus (DM). The results of large clinical trials ADVANCE, ACCORD and VADT definitely proved the role of glycemia control in prevention of microvascular complications of DM. In some studies it was proven that parameters of glycemic variability (GV) are significant in prognosing diabetic retinopathy, nephropathy and cardiovascular complications. The role of hyperglycemia in development of microvascular complication in patients with DM type 2 is not clear at present. Modern approach to DM management as one of the most important methods of micro and macroangiopathies prevention includes necessary glucose self-control. Glycemia self-control should be precise, easy and comfortable letting the patient to have effective and safe hypoglycemic therapy. Choice of glucometer is one of the main aspects of blood glucose self-control. From the point of view of the doctor the most important criteria for glucometer choice is its conformance to standards of accuracy, and from the patient’s point of view - its convenience and ease in use. Because of technological advancements the accuracy of blood glucose level test increases and the procedure of glycemia self-control becomes easier that results in increase of adherence to treatment and hypoglycemic therapy effectiveness. Achievement and sustenance of glycemia target level, prevention of micro and macroangio-pathic complications are impossible without full active participation of the patient in DM treatment and blood glucose self-control with the use of precise and convenient for the patient glucometer such as Contour Plus One.
Consilium Medicum. 2019;21(12):55-58
55-58
THE PLACE OF VITAMIN D SUPPLEMENTATION IN THE COMPLEX THERAPY OF TYPE 2 DIABETIC PATIENTS WITH DIABETIC PERIPHERAL NEUROPATHY
Abstract
Relevance. It is urgent to search for additional opportunities in the prevention and treatment of diabetic peripheral neuropathy (DPN). Aim. To assess the effect of vitamin D on the clinical manifestations of DPN in patients with type 2 diabetes mellitus (T2DM). Materials and methods. 62 patients with T2DM and DPN were randomized to either to receive 5 000 IU (group 1, n=31, F=15) and 40 000 IU (group 2, n=31, F=16) weekly for 24 weeks. At the beginning and at the end of the study determined the levels of 25(OH)D, HbA1C, conducted a survey on the scales of NSS, NDS, NTSS-9 and VAS. The difference (А) in/between the groups according to the studied parameters was estimated. Results. Initially, the groups were comparable in levels 25(OH)D, HbA1C and the NDS, NSS, VAS and NTSS-9 scales (for all р>0.05). In the final significant reduction of symptoms of DPN occurred only in group 2: NDS А=-24.02%, NSS А=-19.63%, VAS А=-11.06%, NTSS-9 А=-24.71 (all р<0.001). In group 1: NDS А=-0.22%, NSS А=6.54%, VAS А=0.84%, NTSS-9 А=-1.03% (all р>0.05). Significant correlations were identified in group 2 between levels of 25(OH)D and: NDS (r=-0.381, р=0.034); VAS (r=0.354, р=0.046); with HbAn, (r=-0.381 р=0.034); BMI (r=-0.388, р=0.031). Conclusions. Taking vitamin D at a dose of 40 000 IU/week of colecalciferol for 24 weeks reduced the severity of neurological symptoms (NDS, NSS, VAS, NTSS-9) in patients with T2DM and DPN and contributed to the improvement of metabolic metabolism (reduction of HbA1C and BMI). Consequently, the addition of 40,000 IU/ week of colecalciferol to patients with T2DM and DPN may affect the severity of DPN.
Consilium Medicum. 2019;21(12):59-66
59-66
MILDRONATE USE IN COMPLEX TREATMENT OF ARTERIAL HYPERTENSION IN PATIENTS WITH ISCHEMIC HEART DISEASE AND ITS INFLUENCE ON HEART AND VESSELS MORPHOFUNCTIONAL STATE
Abstract
The article discusses influence of long-term combined therapy including Mildronate and angiotensin-converting enzyme inhibitor ramipril at endothelium function and heart and vessels morphofunctional state.In recent time cytoprotectors pharmacodynamics of which is characterized by switching cell energy exchange from fatty acids acidification to a more advantageous for oxygen preservation metabolism way - predominant glucose utilization, became more widely used in clinical cardiology practice. At present there are multiple literature reports on effective cytoprotectors use in complex treatment of hypertension. Among cytoprotectors real clinical effects are described in Mildronate. Considering that remodeling processes of left ventricle myocardium and vessel wall are accompanied by free-radical oxidation activation and energy exchange disturbance, and many effects of antihypertensive medications are realized directly through nitrogen oxide system and are associated with vascular endothelium function which are affected in patients with hypertension, Mildronate use in complex treatment of this disorder in patients with ischemic heart disease (IHD) seems to be appropriate. Aim. To determine influence of Mildronate in combination with antihypertensive therapy with angiotensin-converting enzyme inhibitor on severity of left ventricle myocardium hypertrophy, its systolic and diastolic function, intima-media complex thickness in arteria carotis communis, and endothelium dependent vasodilation of brachial artery in patients with hypertension combined with IHD. Materials and methods. The study included 50 patients with stage II hypertension of medium severity. The patients were randomized into 2 groups, 25 patients in each. Ramipril was used for blood pressure decrease. Monotherapy with ramipril was conducted in both groups for 3 weeks. From 21 st day of follow-up peroral Mildronate 500 mg 2 times daily was added to the treatment in study group. The medication was used without interruption for 6 months and then in series of treatment for 2 months with 2 months intervals, the total follow-up period was 24 months. Control group patients received monotherapy with ramipril. Results. It has been established that Mildronate use in combination with traditional antihypertensive therapy with angiotensin-converting enzyme inhibitor ramipril had positive impact on left ventricle hypertrophy severity, systolic and diastolic function, severity of endothelium dysfunction, and intima-media complex thickness in arteria carotis communis that shows promise for Mildronate use in combined treatment of hypertension in patients with IHD. Also the effects of Mil-dronate use are most prominent after long-term systematic use.
Consilium Medicum. 2019;21(12):68-73
68-73
ENDOTHELIN RECEPTOR ANTAGONISTS IN PULMONARY HYPERTENSION TREATMENT
Abstract
The article presents new data on the use of endothelin receptor antagonists (ERA) in treatment of patients with different variants of pulmonary hypertension. The medications mechanisms of action are described and results of clinical studies on effectiveness and safety of the medications, perspectives on ERA use in clinical practice are presented. ERA is one of the best studied class of medications recommended for use in patients with idiopathic pulmonary arterial hypertension (PAH), PAH associated with generalized scleroderma and in Eisenmenger's syndrome in early stages of pulmonary hypertension. It was shown that this group of medications had a positive effect on functional, clinical and hemodynamic parameters, and increases life expectancy and quality of life in these serious cases. These medications are effective not only as monotherapy but also in combination treatment. Among medications for PAH treatment bosentan has the best evidence-based results according to the number of randomized clinical trials. It is the only medication from this group registered in Russia for children treatment. According to Russian register data among ERA in PAH patients 31.6% of patients use bosentan, 3.6% - ambrisentan, and 2.1% - macitentan. Bosentan is the second medication after sildenafil that is being used in PAH, in 31.6 and 54.5% of patients, respectively.
Consilium Medicum. 2019;21(12):74-80
74-80
COMBINATION OF COMPONENTS FOR SUSTENANCE OR IMPROVEMENT OF ELDERLY AND SENIOR AGE PATIENTS’ FUNCTIONAL STATUS (ANTI-AGE MEDICINE)
Abstract
Aging is a process of changing living systems in time, causing disturbances in their structure and functions, which lead to decrease in the reserve capacity of most systems of the human body and is accompanied by related comorbidities, as well as an increase in mortality. The modern theory of pathogenesis of aging is called inlammaging, originated from the English inflammation - inflammation and aging - aseptic, sterile, mild inflammation that is responsible for processes of aging and age-related comorbidities including osteoarthritis, one of the most common diseases among elderly patients. Drugs, which help to slow down the progression of inflammation and used in combination with non-pharmacological methods of prevention of this condition belong to the group of so-called anti-age medicine, as they reduce the severity of age-related problems and syndromes, as well as contribute to the maintenance/improvement of the functional status of the patient. One of these drugs is Alflutop, which contains a combination of components that have an anti-inflammatory effect on osteoarthritis and inflammaging. This article highlights pathogenetic mechanisms of inflammation caused by aging and osteoarthritis, as well as the points of application of the pharmacological action of the components of the drug Alflutop.
Consilium Medicum. 2019;21(12):81-86
81-86
FUNCTIONAL STATE OF THE CARDIOVASCULAR SYSTEM IN PATIENTS WITH ACUTE CORONARY SYNDROME AND TYPES OF BEHAVIORAL ACTIVITY A, AB, B
Abstract
Aim. To study the effect of behavioral activity type on the sympathetic nervous system in patients with acute coronary syndrome - ACS (unstable angina and acute myocardial infarction). Materials and methods. The study included 100 patients with ACS, who were subsequently divided into groups according to the main disease - acute myocardial infarction and unstable angina. The median age was 62.09±5.46 years, therapy according to the underlying disease. All patients had anamnesis of previous and concomitant diseases, anthropometric measurements, physical examination, and observation during the next 24 months after inclusion in the study. In dynamics he carried out daily monitoring of electrocardiogramm, daily monitoring of blood pressure (BP), echocardiography. Diagnosis of types of behavioral activity was carried out using the test method "type of behavioral activity" developed on the basis of the questionnaire Jenkins Activity Survey (JAS), published in 1974 by C. David Jenkins, the Russian-language adaptation was performed in Bekhterev Psychoneurological Research Institute (L.I. Wasserman, N.V. Gumenyuk). Results. Patients with ACS and behavioral type A activity demonstrate increased activity of the sympathetic nervous system in the form of a higher level of systolic and diastolic BP, high variability of BP, increased rate of BP rise in the morning, a higher heart rate during the day in comparison with the types of behavior of AB and B, which can be considered as an unfavorable prognostic predictor of cardiovascular complications.
Consilium Medicum. 2019;21(12):89-94
89-94
REVIEW COMBINED LIPID-LOWERING THERAPY IN EUROPEAN SOCIETY OF CARDIOLOGY AND EUROPEAN ATHEROSCLEROSIS SOCIETY (ESC/EAS) 2019 GUIDELINES: PLACE OF EZETEMIBE
Abstract
The article provides information about the place of ezetimibe in the latest edition of the joint recommendations of the European Society of Cardiology and the European Atherosclerosis Society of 2019, dedicated to the correction of lipid metabolism disorders in order to prevent and treat clinical complications of atherosclerosis. The material of the recommendations is discussed from the point of current conception of the effectiveness and safety of the inhibitor of intestinal absorption of cholesterol - ezetimibe, which is widely used in combined lipid-lowering therapy. The features of the use of ezetimibe in combination with statins to achieve target lipid levels and reduce the frequency of side effects of first-line drugs are detailed. New approaches to stratification of cardiovascular risk in European and Russian recommendations for the diagnosis and treatment of atherogenic dyslipidemia are compared. The possibilities of combined lipid-lowering therapy to achieve new target levels of low density lipoprotein cholesterol in patients with high and very high cardiovascular risk are discussed.
Consilium Medicum. 2019;21(12):95-100
95-100
BURNOUT AS PROFESSIONAL PROBLEM OF MODERN PUBLIC HEALTHCARE
Abstract
In the review, there are demonstrated risk factors and basic pathogenetic mechanisms of the development of professional burnout among healthcare workers and students. Burnout is established already within the first year of medical education, the total rate of burnout among healthcare workers’ reaches 50%. The consequences of this state are accompanied by significant decrease in the quality of rendering medical aid. For healthcare workers, negative consequences of burnout have a wide character and include decrease in the quality of work with patients, increase in taking anxiolytic drugs, elevated suicidal risk, they cause reduction in the quality of life, development of organic and psychologically conditioned diseases. Professional burnout is of multifactor origin, it includes combination of personal, psychodynamic, professional and ecological factors, which can provoke burnout. The reasons of this state, directly connected with work, are the following: long working day, large number of problems to be solved simultaneously, insufficient supply of resources, poor social support. Burnout is a syndrome, including three key elements: emotional exhaustion, depersonalization (cynicism) and low estimation of personal achievements. Special attention should be paid to rehabilitation and prognosis for this pathology. Psychological training, optimization of productivity and improvement of working conditions contribute to reduction of emotional exhaustion and depersonalization, decline in psychological load among healthcare workers. In fight with burnout, very important are preventive measures, including optimization of interpersonal relationships in collectives and regulation of communication with patients, creation of possibilities for career development, growth of salary.
Consilium Medicum. 2019;21(12):101-105
101-105
POSSIBILITIES OF PHARMACEUTICAL TREATMENT OF CARDIOGENIC ENCEPHALOPATHY WITH THE USE OF RUSSIAN MEDICATION WITH METABOLIC ACTION LEVOCARNITINE IN PATIENTS WITH ISCHEMIC HEART DISEASE AND CONGESTIVE HEART FAILURE
Abstract
Background. In recent years, interest in metabolic therapy with myocardial and cerebral cytoprotectors has increased. Given the results of clinical studies of levocarnitine, indications for its use are clarified and the therapeutic niche of this drug is established in patients with coronary heart disease (CHD) and chronic heart failure (CHF) with cardiogenic encephalopathy. Aim. To study an efficacy and safety of a metabolic drug levocarnitine in the treatment of patients with coronary artery disease complicated by chronic heart failure with preserved ejection fraction (CHF-pEF) and cardiogenic encephalopathy. Materials and methods. In the open comparative study 120 patients with stable angina pectoris of II-III functional class (FC) associated by CHF-pEF of II FC were divided into 2 groups which were comparable by age and gender. In one group, Elkar® solution for intravenous and intramuscular administration, manufactured by «ПИК-ФАРМА» (Russia) 100 mg/ml was prescribed in addition to the standard therapy. To evaluate cognitive indexes a brief scale of assessment of mental status (Mini-Mental State Examination) was used. Results. In the group treated with levocarnitine, there was a significant improvement in cognitive indexes compared with the control group, as well as a beneficial effect on the left ventricle diastolic function and exercise tolerance was identified. Conclusions. Levocarnitine is an adjunct (to the basic treatment of CHD and CHF) effective metabolic drug with cardio- and cerebroprotective effects in the treatment of patients with CHD, complicated by CHF-pEF and cardiac encephalopathy. It proved to be a safe, well-tolerated drug.
Consilium Medicum. 2019;21(12):106-111
106-111
ANTIARRHYTHMIC MEDICATION PROPAFENONE: PLACE IN CLINICAL PRACTICE (REVIEW)
Abstract
Currently, antiarrhythmic drugs are widely used in clinical practice, influencing the clinical manifestations of arrhythmias, which can significantly improve the quality of life of patients. A key issue in antiarrhythmic therapy is ensuring the safety of treatment. Propafenone stands out among all antiarrhythmic drugs by the presence of a large evidence base obtained in various groups of patients, efficacy and safety, as well as the availability of both oral and intravenous forms of administration. In patients without a pronounced organic lesion of the heart, propafenone is the drug of choice in a large number of clinical situations: extrasystole, supraventricular tachycardia, atrial fibrillation and atrial flutter, and even certain types of ventricular tachycardia.
Consilium Medicum. 2019;21(12):112-117
112-117
2018 AND 2019 GUIDELINES FOR THE MANAGEMENT OF ARTERIAL HYPERTENSION: IS THERE A PLACE FOR UNFIXED DRUG COMBINATIONS?
Abstract
The end of 2018 and the beginning of 2019 were marked by 2 important events in medicine, namely the release of new European and Russian guidelines for the management of arterial hypertension. For most patients, fixed combinations of antihypertensive drugs are recommended as first step treatment. Today, in the Russian Federation, despite the variety of fixed drug combinations there are combinations that are effective, meet the latest recommendations, but are not currently presented in fixed form, for example, a combination of indapamide and angiotensin II receptor blocker. Indapamide not only effectively reduces blood pressure, but also has a number of organoprotective effects (cerebro-, cardio- and nephroprotective). The data of PROGRESS (Perindopril protection against Recurrent Stroke Study) and PATS (Post-stroke Antihypertensive Treatment Study) studies on indapamide provided the basis of American recommendations for the secondary prevention of stroke, and HYVET-COG (Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment) study showed a decrease in the risk for dementia in patients treated with indapamide. These data, along with the results of other placebo-controlled studies, were included in the meta-analysis mentioned above, a statistically significant decrease in a risk of dementia was noted in the “antihypertensive treatment” group compared to placebo. Angiotensin II receptor blockers also have marked organoprotective effect and a large evidence base on their ability to reduce the risk for coronary and cerebrovascular (stroke, dementia) complications. One more effective unfixed drug combination that is not registered on the market is a combination of nitrendipine and indapamide, which can be effectively used not only to lower blood pressure, but also to prevent dementia, including in Alzheimer's disease. Thus, although the new European and Russian guidelines give preference to fixed combinations of antihypertensive drugs, there are clinical situations where it seems appropriate to consider prescribing unfixed combinations of antihypertensive drugs.
Consilium Medicum. 2019;21(12):118-127
118-127
INFLUENCE OF TAURIN AT THE DEGREE OF INTERNAL OBESITY AND SEVERITY OF VISCERAL FAT DYSFUNCTION IN PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE
Abstract
Aim. To evaluate influence of 24 weeks taurin therapy on level of internal obesity and severity of visceral fat dysfunction in patients with non-alcoholic fatty liver disease (NAFLD). Materials and methods. A prospective comparative randomized trial that included 90 patients with NAFLD was conducted. NAFLD was diagnosed according to liver ultrasound results (using Siemens Sonoline G50, Germany ultrasound system with Doppler device and evaluation of liver parenchyma echogenicity, vascular pattern, and degree of distal echo signal attenuation). Using simple randomization method the patients were divided into 2 groups: group 1 (study group) included patients with NAFLD receiving taurin 1000 mg per day (500 mg 2 times daily) in addition to daily therapy for coexisting disorders (type 2 diabetes mellitus, ischemic heart disease, arterial hypertension) and group 2 (control group) that included patients with NAFLD receiving only baseline therapy. Body composition analysis with evaluation of visceral fat percentage content using bioelectrical impedansometry (Omron BF508 52, Japan) was performed, internal obesity index and severity of visceral fat dysfunction were determined at baseline and after 24 weeks of treatment. Carbohydrate metabolism state was controlled according to following parameters: fasting glucose serum level, basal insulin level, and Homeostasis Model Assessment of Insulin Resistance HOMA-IR. Total cholesterol, triglycerides, low-density lipoprotein, and high-density lipoprotein levels were evaluated for lipids metabolism status evaluation. Results. In patients with NAFLD severe internal obesity and severe visceral fat dysfunction worsening in proportion to obesity degree increase were observed. It was shown that use of 1000 mg taurin per day for 24 weeks in treatment of patients with NAFLD results in significant decrease of internal obesity degree according to bioimpedansometry, internal obesity index, and decrease of visceral fat dysfunction.
Consilium Medicum. 2019;21(12):128-133
128-133
PURINE METABOLISM DISORDERS: DIAGNOSIS AND TREATMENT (CLINICAL LECTURE)
Abstract
In a form of a clinical lecture the article presents data on significance of purine metabolism disorders in pathogenesis of some frequent internal diseases and uric acid nephrolithiasis, their incidence and meaning in modern medical practice. On the basis of most modern data on pathogenesis of purine metabolism disorders its diagnosis and treatment with xanthine oxidase inhibitors, aspects of allopurinol treatment and advantages of the most modern medication febuxostat are described. From urologist point of view a tight pathogenic association of purine metabolism disorders with development of uric acid nephrolithiasis, diet therapy and medical treatment are rationalized including hyperuricemia correction with xanthine oxidase inhibitors.
Consilium Medicum. 2019;21(12):134-138
134-138
URINARY TRACT INFECTIONS IN PATIENTS WITH NEUROGENIC BLADDER
Abstract
Diagnosis, treatment and prophylactic of urinary tract infections (UTI) in neurogenic bladder patients is one of the most difficult problems of antimicrobial therapy in urology. There are no clear definition of symptomatic UTI in this group, leading to unreasonable use of antibiotics and microbial resistance. Infection resistance and recurrence associated with extensive catheters use and with other little known factors such as urodynamic dysfunction, detrusor over activity, vesicoureteral reflux, post-void residual urine, changes in microbiome, decreasing in local and general immunity. The prophylaxis of UTI in neurogenic low urinary tract dysfunction is primarily a question of a proper correction of urodynamic dysfunction and rational use of antimicrobial drugs.
Consilium Medicum. 2019;21(12):139-144
139-144