Vol 86, No 11 (2014)

In 2013, 80,000 new cases of infection caused by human immunodeficiency virus (HIV) (HIV infection) were registered in Russia; there have been a total of as many as 850,000 notified HIV-infected cases in this country, which suggests that the HIV/AIDS epidemic becomes generalized. Of them, 150,000 people have died, most (22,000) cases in 2013, predominantly due to the late diagnosis of HIV infection and its delayed treatment initiation. The rise of new cases denotes that counteraction against the spread of HIV is inadequately effective; in this connection a further increase in morbidity and mortality rates should be forthcoming. However, the medical community has proved to be poorly trained to fight the epidemic; there is a lower awareness and knowledge about HIV infection among healthcare workers. To overcome the epidemic and its imminent negative implications, it is necessary to improve an epidemiological surveillance system, to introduce proven effective methods for the prevention of the disease, to increase patient access to current treatments, which will require not only higher direct expenditures on preventive measures, the creation of an infrastructure, and the purchase of medicaments and diagnostic agents, but also on the training and retraining of a large number of healthcare workers.

AIM. To study the awareness of HIV infection in the dwellers of the Central Administrative District of Moscow. MATERIALS AND METHODS. A continuous cross-sectional survey was made in all the citizens who applied to the V.A. Gilyarovsky Mental Hospital Three, Branch Four, for information on the day of the survey and gave their consent to participate in this survey that was performed in 4 steps; a total of 414 persons were questioned. Their knowledge and ideas were anonymously assessed using a specially developed questionnaire. After analyzing their replies, the respondents were divided into 3 groups: 1) representatives of the so-called general population; 2) draft-age youngsters; 3) health care workers. RESULTS. The draftees (34%) gave the largest number of wrong answers to the question whether human immunodeficiency virus (HIV) could be transmitted through mosquito bites (p=0.0001). Among the healthcare workers, 81% of the respondents indicated that HIV could not be transmitted through mosquito bites; the proportion of right answers among the general population was 64.3%. The statement that a condom reliably protects against HIV infection was considered to be true by 52.4% of the health care workers, 56% of the draftees, and 62.2% of the representatives of the general population. The HIV/AIDS topic was not relevant for 43.4% of the general population and 58.3% of the health care workers; 98.7% of the respondents of the general population pointed that blood should be sampled for testing for HIV antibodies to find out whether a person had HIV (AIDS); this answer was chosen by 87.5% of the surveyed health care workers. CONCLUSION. Low knowledge about HIV infection particularly among the draft-age youngsters is evidence for the insufficient efficiency of performed preventive measures among both the general population and the organized young people. Attention is drawn to the opinion of the respondent health care workers as to the reliability of using the condom to prevent HIV transmission. The findings will be kept in mind when elaborating the teaching programs.

AIM. To analyze the data of magnetic resonance imaging (MRI) of the brain in its toxoplasmosis in HIV-infected patients. Subject and methods. The clinical picture of cerebral toxoplasmosis was studied in 207 patients aged 18-76 years with Stage 4B HIV infection concurrent with the disease. Brain MRI using an Obraz-1 low-field (0.12 T) MRI scanner (Russia) was carried out in 115 (55.5%) patients. This investigation was conducted in 74 (65%) treated patients over time. RESULTS. Brain T2-weighted and FLAR MRI scans most frequently revealed higher-signal polymorphic foci and T1-weighted MRI scans showed lower-signal ones predominantly involving the white matter or white-grey matter border. Perifocal edema was often recorded. Intravenous gadolinium contrast study indicated that these foci accumulated the contrast agent around the periphery following the target patterns. Sixty-four (86.5%) patients were observed to have significant positive changes: reductions in the number and sizes of foci and the area of perifocal edema; in 29 patients, the inflammatory foci changed into cysts as a favorable outcome of necrotizing encephalitis. The foci resolved completely only in 7% of the patients. CONCLUSION. MRI is of great importance in intensive care, neurology, or neurosurgery units where patients with cerebral toxoplasmosis mimicking an acute cerebrovascular accident or a brain tumor are particularly frequently admitted to.

AIM. To evaluate the efficiency and safety of using raltegravir (RAL) twice daily in conjunction with a once-daily fixed dose combination of abacavir (ABC)/lamivudine (3TC) in patients with HIV infection and active tuberculosis who have not previously received antiretroviral therapy (ART) and have taken rifabutin as antituberculosis therapy (ATT). MATERIALS AND METHODS. The efficiency of ART was evaluated in 28 patients from a change in HIV RNA levels and from an increase in CD4+ lymphocyte counts during 48-week treatment that had been completed by 15 (53.6%) patients. The main reason for therapy discontinuation was that the patients returned to the use psychoactive agents. RESULTS. After 24 and 48 weeks of ART, the level of HIV RNA reached the undetectable values (less than 50 copies/ml) in 81.25 and 75% of the patients, respectively (according to an analysis including the patients who had completed the study in conformity with the requirements of the protocol). In only 2 patients, the virological therapy proved to be ineffective, which was likely to be associated with noncompliance with drug therapy. Following 24- and 48-week therapy, the increase in median CD4+ lymphocyte counts was 70 and 208.5 per µl, respectively. The concurrent use of ART and ATT caused positive changes in the lung skiagraphic pattern in 92.9% of the patients and complete resolution of lung tissue infiltration in 71.4%. Mixed infection ended in a fatal outcome caused by a progressive tuberculous process in 3 (10.7%) patients, in 2 of them within the first 8 weeks of treatment. The concomitant use of ATT including rifabutin and an ART (RAL + ABC/3TC) regimen was safe since one patient was noted to have a RAL-related adverse event (AE) (an allergic reaction) and caused the patient to discontinue therapy. ATT was not discontinued because of AE in any case. CONCLUSION. The ART regimen containing RAL and a fixed dose combination of ABC/3TC for adult patients with tuberculosis concurrent with HIV infection who are on combined therapy using rifabutin for tuberculosis may be recommended for the treatment of this category of patients.

AIM. To comparatively characterize clinical, biochemical, and hemostasiological parameters in patients with chronic alcoholic hepatitis (CAH) and chronic mixed hepatitis (CMH), i.e. CAH + chronic hepatitis C. MATERIALS AND METHODS. Sixty-three patients (mean age 39.05±4.95 years) with chronic hepatitides of different etiology, who underwent general clinical, biochemical, and hemostasiological studies, were examined. RESULTS. The frequency and duration of major clinical symptoms were maximally pronounced in the patients with CMH. Aspartate aminotransferase concentrations were significantly decreased only in the patients with CAH, remaining at higher levels in CMH. The activity of γ-glutamyl transpeptidase was twice higher in CAH. In the patients of both groups, the total concentration of nitrates and nitrites was recorded within the normal range and the activity of von Willebrand factor was significantly higher than normal. The aggregation of platelets and erythrocytes in the patients of all the groups was significantly lower than that in the healthy individuals, but differed at different disease stages. CONCLUSION. CMH was ascertained to have a more severe course. The hemostatic system did not significantly depend on the etiology of hepatitis, but was variable in different periods of various hepatitides.

AIM. To assess the results of diagnosing and treating Pneumocystis pneumonia (PP) in patients with Hodgkin lymphoma (HL) over 15 years. MATERIALS AND METHODS. In 1999 to 2013, PP occurred in 22 (3%) of 741 HL patients receiving programmed polychemotherapy (PCT). The male/female ratio was 1:1.1; median age was 32 (18-65) years. Advanced stages (IIB-IV) of the disease were seen in 82% of the patients. The diagnosis of PP was established when Pneumocystis (more than 5 cysts in the specimen) was detected in the lavage fluid by indirect immunofluorescence assay. RESULTS. PP developed after 4 or more cycles of PCT. Along with Pneumocystis, all the cases were found to have additional pathogens: herpes virus in 72% and bacteria and fungi in 33%. All the patients received combined antimicrobial therapy using high doses of intravenous trimethoprim-sulfamethoxazole. Ten (45%) patients required mechanical ventilation (MV). The total mortality in PP was 32% (7 patients died); moreover, none of the patients without MV died whereas the mortality among those who had MV was 70% (7 of the 10 patients died). High death rates (80%) were noted among the patients with recurrent and resistant HL. CONCLUSION. PP should be prevented with trimethoprim-sulfamethoxazole in patients with LH during PCT. If respiratory failure and X-ray signs of interstitial pneumonia appear, there is a need for fibrobronchoscopy with bronchoalveolar lavage and comprehensive microbiological testing of lavage fluid.

Aim: to establish the features of clinical and laboratory changes in facial erysipelas in relation to its form. MATERIALS AND METHODS. Twenty-three patients (15 women and 8 men) aged 31 to 78 years who were diagnosed with moderate facial erysipelas, primary facial erysipelas being present in 91% of cases were examined. The investigators studied the biochemical substrates and enzymes and composition of proteins in the serum by an electrophoretic method, the aggregation activity of red blood cells and platelets, plasma hemostasis (a coagulogram, levels of fibrinogen, antithrombin III, and D-dimer), and von Willebrand factor, a marker of vessel wall injury, on hospital admission at disease onset (days 1-3), over time (days 4-6, 7-9), and in convalescence (days 10-12), by obligatorily using control materials. CONCLUSION. Bleeding disorders in facial erysipelas correspond to the vasculite purpuric type of hemorrhagic diathesis (according to the classification developed by Z.S. Barkagan) with the laboratory signs of evolving disseminated intravascular coagulation: impairments in erythrocyte hemostasis and blood vessel endothelium. The changes in the functional properties of red blood cells match with the suppression of metabolic processes. And if the neuraminidase effect of Β-hemolytic streptococcus is shown at the level of the red blood cell membrane, the activity of NADase blocks processes in the entire macroenergetics. In the presence of a high fever reaction, the low levels of transaminases (aspartate aminotransferase, alanine aminotransferase) and membrane enzymes (alkaline phosphatase, creatinine phosphokinase) decrease the detoxification capacities of serum and increase a load on blood albumin and erythrocyte barriers. Rapid normalization of C-reactive protein levels enables one to use this simple and highly sensitive test to monitor the involution of erysipelatous inflammation and the efficiency of treatment. The changes in the hemostatic system and metabolic tests are less pronounced in patients with facial erysipelas than in those with lower-extremity erysipelas.

The paper describes a clinical case of South African tick bite fever in a group of Russian tourists. The group of 5 people who had been ill with this disease after a tourist trip to the South African Republic (the Kruger National Park in the north-eastern province of Mpumalanga) were followed up. During their trip, all of them were bitten by different insects many times. The disease exhibited different clinical presentations; however, all the patients were noted to have a fever with slight intoxication and a maculopapular rash at different sites of the body; 3 had lymphadenopathy and one had a primary effect at the site of tick sticking. The diagnosis was verified by indirect immunofluorescence for the detection of high titers to Rickettsia сonorii. The course of the disease was favorable in all the patients treated with antibiotics (doxycycline or ceftriaxone).

The paper describes a clinical case of pulmonary vasculitis caused by hepatitis C virus (HCV). Its diagnosis was established on the basis of in-depth laboratory testing and an investigation of the molecular biological markers of viremia (polymerase chain reaction - PCR - HCV RNA) in peripheral blood mononuclear cells. By taking into account of extrahepatic HCV replication and contraindications to interferon therapy, the female patient was given an interferon-free antiviral therapy cycle using an interferonogenic inductor in combination with ribavirin. Pathogenic therapy (methylpred and ursodeoxycholic acid) was additionally performed. An interferon-free regimen of cycloferon + ribavirin led to sustained remission of HCV infection running with its systemic manifestations. The therapy could improve the function of not only the liver, but also the lung. In suspected extrahepatic HCV infections, an investigation of molecular biological markers for viremia (HCV RNA PCR) in the peripheral blood mononuclear cells is an essential diagnostic technique. Interferonogenic inductors, cycloferon in particular, should be used in combination with ribavirin when a chronic hepatitis C patient with the extrahepatic manifestations of HCV infection has contraindications to conventional therapy with recombinant interferon-α.

The goal of treatment for chronic hepatitis B (CHB) is now to improve quality of life and to prevent the poor outcomes of the disease rather than to eliminate the virus from the body. This goal may be achieved via the long-term maintenance of aviremia. According to the International and Russian clinical guidelines, entecavir is the first-line drug of choice to treat patients with CHB. For almost 10 years of world clinical practice there has been evidence that entecavir has a high efficacy and a favorable safety profile in a number of randomized clinical trials and in real medical practice worldwide, in Russia in particular. For instance, the BRAVR (Baraclude Russian Analysis of Virological Response) trial of 147 CHB patients from 10 Russian cities indicated that the rate of aviremia was 85.8% (n=147), 89.9% (n=138), 89.4% (n=97), and 93.5% (n=81) at 1, 2, 3, and 4 years, respectively. In addition to its virological, immunological, and biochemical efficacies, entecavir also proved to be effective in achieving the regression of histological changes and in preventing the decompensation of cirrhosis and the development of carcinoma. The given data permit the use of entecavir for the long-term therapy of CHB with confidence.

The paper reviews the state-of-the-art of acute respiratory distress syndrome (ARDS) and current approaches to correcting respiratory failure. It highlights the historical and present-day data on the efficiency of extracorporeal membrane hemoxygenation, high-frequency ventilation, surfactant and inhaled nitric oxide therapy, and prone ventilation. The examinations have shown that ventilation in the prone position and extracorporeal membrane hemoxygenation not only improve gas exchange, but have a positive prognostic impact. The use of inhaled nitric oxide and surfactant achieves improved oxygenation for a while, but has no substantial effect on prognosis. The place of high-frequency oscillatory ventilation in the treatment of patients with ARDS has not been fully determined as some examinations have indicated a positive prognostic impact and other examinations have shown none or a negative impact.

The problem of cognitive dysfunctions in patients with somatic diseases occupies a prominent place now since they are one of the most common manifestations of organic brain lesions. The early detection of potentially cured cognitive impairments is one of the important tasks of a present-day therapist, cardiologist, endocrinologist, and family doctor as the patients with early-stage cognitive impairments constitute the majority of those who have sought medical advice. In the modern world, primary health care physicians' actions are decisive in predicting the development of dementia since the detection of early non-dementia forms of cognitive impairments and neuroprotective therapy with mexidol in particular are frequently quite sufficient to considerably reduce the degree of the impairments and to improve the prognosis of dementia.