Volume 27, Nº 13 (2020)

As compared to the treatment of patients with severe and extremely severe coronavirus infection (COVID-19), the use of glucocorticosteroids (GCS) for mild cases is not indicated. In line with the recommendations of the Ministry of Health of the Russian Federation, GCS therapy at the outpatient stage is allowed only for patients who meet the criteria for a moderate course, taking into account a number of restrictions and with a thorough assessment of the risk of side effects. Foreign recommendations declare rather against the routine use of GCS outside of situations of severe and extremely severe course.

Results from several randomized clinical trials of remdesivir show that patients who received remdesivir, had clinical improvement compared with patients who received placebo, as well as reduced disease progression in patients requiring oxygen therapy. Clinical trials have not obtained convincing data on the effect of the drug on outcomes incl. death from COVID-19. In accordance with the instructions for use of the drug remdesivir against SARS-CoV-2: use only in inpatient settings and only for patients with saturation less than 94% or who need some form of respiratory support.

Cardiovascular diseases remain the leading cause of death worldwide, and today there is growing evidence of the important role of intestinal barrier disorders and microbiota imbalances in the development and progression of cardiovascular pathology. In this matter, changes in the structure of tight junctions between enterocytes of the intestinal mucous membrane have the leading importance, because normally they provide its barrier function, preventing the penetration into the systemic circulation both pathogens antigenic determinants and toxic products and biologically active substances. Impaired tight junctions and increased gastrointestinal mucous membrane permeability can be mediated by various mediators such as zonulin, an intestinal fatty acid-binding protein, as well as individual representatives of short-chain fatty acids. Increased intestinal permeability as well as its dysbiosis play a crucial role in the atherosclerosis progression, contributing to an increase in proinflammatory cytokines, chemoattractant molecules, and enhanced platelet reactivity. An important role in these processes is also played by trimethylamine oxide (TMAO), formed from the precursor synthesized by the intestinal microbiota. There is evidence that an elevated TMAO increases the risk of major adverse cardiovascular events, including death, myocardial infarction, and stroke. TMAO contribute to the atherosclerosis progression through various mechanisms - its inhibits the cholesterol reverse transport, which leads to its excretion impairment from macrophages and creates conditions for their transformation into foam cells and reduces the antiatherogenic effects of high density lipoproteins. The intestinal barrier and altered microbiome also contribute to the blood pressure dysregulation and predispose to arterial hypertension. The oxidized lipoproteins, which enter the bloodstream through the leaky intestinal mucosa, is also play important role in blood pressure increasing. A unique drug that can normalize the intestinal barrier function due to tight junctions’ repair is rebamipid. Distinctive features of this drug are its effectiveness throughout the whole gastrointestinal tract, as well as a wide range of pleiotropic effects, due to which rebamipid provides comprehensive mucous membrane protection at all three levels of its structural organization: at the preepithelial level, stimulating the mucins formation; at the epithelial level, restoring tight junctions and accelerating the cells regeneration; and subepithelial level, improving microcirculation in deep mucosa. Rebamipid has been used in clinical practice for a long time, due to this fact it has a wide body of evidence of high efficiency and safety, confirmed not only in experimental studies, but also in clinical trials. Additional, extremely important for cardiological patients, effects of rebamipide include directly anti-atherosclerotic and anti-inflammatory effects in the vascular bed, a beneficial effect on endothelial function and the activity in relation to the intestinal microbiome regulation. It was shown that rebamipid reduces the severity of intestinal mucosa damage induced by non-steroidal anti-inflammatory drugs, increases the lactobacilli level in the microbiome and reduces pathogenic bacteroids and clostridia. From the safety point of view, it is extremely important that even the triple rebamipide dose, studied in cardiologic patients, did not lead to the adverse drug reactions development. Such multifactorial pleiotropic rebamipide effects make it possible to consider it as a promising drug not only in the gastroenterologists’ practice, but also in the management of comorbid patients with cardiovascular diseases, including ischemic heart disease and arterial hypertension.

The number of cases of drug-induced liver damage (DILI) is about 10% of all adverse drug reactions (ADRs). Cholestatic variant accounts for 20% to 40% of all DILIs. The development of this type of ADRs is associated with use of many classes of drugs, among which, special attention is payed to drugs for the treatment of the cardiovascular system (antiarrhythmics, antihypertensive drugs, anticoagulants, antiplatelet agents, etc.) due to their frequent use in clinical practice. The mechanism of liver damage includes immune-mediated, allergic and idiosyncratic reactions. Alertness of practical health care professionals regarding the potential hepatotoxic effect of drugs and its timely diagnosis will improve the safety and prognosis of patients receiving treatment for cardiovascular diseases.

The use of antiplatelet agents and anticoagulants in cardiological practice is associated with an increased risk of developing erosive and ulcerative lesions of the mucous membrane of the gastrointestinal tract (GIT) and the risk of gastrointestinal bleeding. Since antithrombotic drugs are usually prescribed for a long period of time, it is critical to ensure adequate protection of the gastrointestinal mucosa from their damaging effects to increase the safety of treatment. For this purpose, proton pump inhibitors (PPIs) are usually prescribed, but long-term use of PPIs is often accompanied by the development of side effects and is associated with an increased risk of death. In addition, PPIs not only fail to protect the intestinal mucosa from the damaging effects of antithrombotic drugs, but can also provoke bleeding from the lower gastrointestinal tract. In this regard, it seems reasonable to use gastroprotectors that have a mechanism of action different from PPIs, for example, rebamipide, a unique drug that combines the properties of a gastro- and enteroprotector. Numerous studies have proven the effectiveness of rebamipide in gastro- and enteropathy associated with the use of antiplatelet agents, incl. dual antiplatelet therapy. There is also evidence of the efficacy of rebamipide for dyspepsia associated with dabigatran. The available evidence base allows to recommend rebamipide for protecting the gastrointestinal mucosa and increasing the safety of treatment in patients taking antiplatelets and anticoagulants for a long time.

Background. Pathogenetic therapy of chronic cerebral ischemia (CCI) should be aimed at optimizing cerebral blood flow and creating neurometabolic brain protection against ischemia and hypoxia. Objective. Evaluation of the efficacy and safety of therapy with the antioxidant ethylmethylhydroxypyridine succinate at a dose of 250 mg 3 times a day for 60 days in patients with CCI against the background of arterial hypertension and atherosclerosis. Methods. The study included 40 patients aged 45-75 years with a verified diagnosis of CCI, randomized into 2 groups: 1 - the main group receiving treatment with ethylmethylhydroxypyridine succinate 250 mg, 2 - the control group receiving treatment as part of the correction of risk factors in accordance with generally accepted standards for the management of arterial hypertension and atherosclerosis. Effectiveness of therapy was assessed using the CGI, MoCa, MFI-20, and Tinnetti scales. Results. Against the background of treatment with ethylmethylhydroxypyridine succinate 250 mg, the main group showed a significant decrease in the severity of asthenia symptoms according to MFI-20, an increase in mental capacity and task performance speed according to MoSa, and an increase in motor activity according to the Tinneti scale. The drug proved to be safe when used at a dose of 750 mg/day in the treatment of CCI for 2 months. Conclusion. The results of using the ethylmethylhydroxypyridine succinate indicate its efficacy and safety in the treatment of the main neurological and neuropsychiatric CCI symptoms. Ethylmethylhydroxypyridine succinate at a dose of 250 mg 3 times a day can be recommended for the treatment of CCI in patients with arterial hypertension and atherosclerosis.

Background. The growing incidence, significant economic losses, costs of compulsory health insurance and high-tech medical care have turned the problem of lumbar osteochondrosis into a socially significant one. Relevance of this problem is determined by the need to study the etiopathogenesis, course of degenerative process for an integrated approach to the selection of an adequate treatment. Objective. Evaluation of the microelement composition of biomaterials represented by tissue fragments of the removed part of the herniated intravertebral disc (IVD), obtained intraoperatively, using instrumental neutron activation analysis (INAA). Methods. The study included patients with hernias of the lumbar spine, divided into three groups depending on the stage of development of the disc herniation and age. The examination of biomaterial samples for the content of macro- and microelements was carried out using INAA, which made it possible to determine the content of 22 microelements in IVD tissues with degenerative-dystrophic changes. Results. Analysis of the data obtained revealed that in IVD tissues there is a gradual change in the content of a number of essential elements, depending on the stage of development of degeneration. Conclusion. The correlations of the microelement composition of the disc tissues and the course of the degenerative process revealed in this study can be used to predict the patient’s condition and select an adequate treatment.

Background. Cognitive impairment (CI) in ischemic stroke (IS) patients occupies up to 80% in the general classification. It is they that can challenge the rehabilitation, noticeably worsening the overall quality of life of a patient, as well as increasing the likelihood of developing a recurrent cerebral infarction. Objective. Evaluation of the effectiveness of transcranial magnetic stimulation in the complex treatment of patients with CI in the late recovery period of IS. Methods. In 2017-2019, a non-randomized prospective study included 200 neurologic patients who experienced acute ischemic cerebrovascular accident in the late recovery period. All patients were divided into two groups: group I (main)-100 patients (52 men and 48 women aged 45-75 years) and group II (control) - 100 patients (55 men and 45 women aged 45-75 years). Treatment efficacy was assessed by methods for quantifying the neurological deficit and associated conditions using the integral scales (Scandinavian Stroke Study Group (SSSG), National Institutes of Health Stroke Scale (NIHSS), Barthel Index, Rankin scale), and quantitative assessment of basic cognitive functions by the neuropsychological testing (tests to assess attention, perception, memory, mental functions, impaired speech function, MMSE scale). Results. Compared to the control group, patients of the main group showed a statistically significant improvement according to most methods for assessing CI, as well as a significant improvement in the overall neurological deficit. Conclusion. The inclusion of transcranial magnetic stimulation in the complex treatment of CI in patients in the late recovery period of IS leads to an improvement not only in particular cognitive functions: attention, perception, memory, motor speech and praxis, but also in general cognitive status, which is confirmed statistically by the results of its integrated assessment.

Despite the seeming triviality, the task of diagnosing and treating back pain is far from simple: first, it is required to identify the cause of the pain, which does not always lie on the surface, and to exclude a number of conditions that pose a threat to the patient’s health and life; secondly, it is necessary to find an effective treatment. The problem of treating patients with back pain is the frequent chronicity of pain syndrome, which sharply worsens the prognosis of recovery. Timely relief of acute pain and adequate selection of pain relievers can resolve this issue in more than half of patients. The appointment of non-steroidal anti-inflammatory drugs (NSAIDs), which is necessary for acute dorsalgia and is often required in cases of chronic pain, should be carried out taking into account not only the effectiveness, but also the safety of using these drugs individually for each patient. Most elderly patients with concomitant somatic pathology have an average or high risk of developing undesirable side effects with NSAIDs. Among all NSAIDs, coxibs are considered the most selective in terms of their effect on cyclooxygenase-2 and the least toxic in terms of their effect on the gastrointestinal tract. In particular, etoricoxib proved to be an effective drug for the relief of acute and chronic pain, according to international studies and meta-analysis, the risk of negative effects of etoricoxib on the gastrointestinal tract is lower than that of diclofenac and is comparable to the latter in terms of cardiovascular complications. Nevertheless, it is not recommended to use any NSAIDs for a long time, and the selection of the drug should be carried out individually, taking into account the existing concomitant diseases.

One of the main global strategies of healthcare in 21st century is medical rehabilitation. The rapidly growing number of patients, who survive after stroke, substantiates the need for the development of effective methods of assessment of disability and rehabilitation, aimed at maximal recovery of neurological impairments. In this article we present a clinical case of a young female patient with stroke, who demonstrated good recovery of motor and sensory functions. We demonstrated the importance of timely and adequate assessment of neurological impairment and delineation of treatment goals in patient with spastic paresis and sensory impairment. We also highlight the importance of diagnostics of spasticity and prevention of its further progression and minimization of its negative influence on motor recovery process of the limb. Moreover, we substantiate the need for the identification of predictors of the development of spasticity, including sensory deficit in paretic limbs, for adequate development of rehabilitation program. We provide a detailed analysis of the diagnostics of sensory impairment in limbs and approaches for recovery and rehabilitation. We demonstrate the role of botulinum toxin therapy in interdisciplinary and integrated rehabilitation programs in patients with spastic paresis and the essential role of the principle of intensity and continued self-rehabilitation in patients with spastic paresis.

Background. Currently, strokes, especially in young patients, are a significant medical and social problem. Differential diagnosis of the causes of stroke development in young patients is important from the point of view of the prevention of recurrent events. Description of the clinical case. This article examines a clinical case of multiple thrombotic events in a young woman with congenital thrombophilia (heterozygous FII [prothrombin] gene mutation) in combination with pulmonary arteriovenous malformation. Conclusion. A comprehensive examination and determining the mechanisms of thrombosis development made it possible to determine the individual risk factors, treatment tactics for the patient, which dramatically reduced the risk of recurrent cerebrovascular accidents. The identification of hereditary disorders determined not only the possibility of secondary prevention of the disease in the patient, but also the dynamic follow-up and primary prevention for her children.