No 2 (2017)

In recent years, there is a need to update the views on the improvement of the mechanism of education of doctors, which would have a maximum effective impact on the quality of medical care. At the moment, the new format of the education includes training with the use of simulation technologies. Simulation training allows to conduct an effective high effective education using innovative technologies in a fairly short period of time taking into account the initial level of medical knowledge. Another advantage of simulation technology is indefinite skill training without risk for the patients. We have developed and implemented training courses using simulation technologies for primary care physicians «Standardized patient in the practice of the therapist». As a result, expected result of training has been received, namely, improvement of the quality of medical care. Also, analysis of the work of doctors after training showed that the time of doctor's appointment became stable (11 minutes), which suggests a more careful management of patients; patient's waiting time reduced (4.6 minutes); the number of calls regarding hypertensive crises decreased: 28% in April and 27.3% in May, 2015, compared to 21.1% in April and 23.4% in May, 2016; pronounced decline in over-diagnosis of CHD after the training of doctors was observed. Thus, after training using novel simulation technologies the work of therapist becomes more stable, clear; doctors demonstrate developed tactics and decision-making algorithm in different clinic situations.

Stroke prevention is the most important task of treating patients with non-valvular atrial fibrillation (AF). The most effective way for prevention of ischemic stroke in AF includes indefinite (life-long) use of oral anticoagulants. Long-term use of anticoagulants is associated with increased risk of bleeding. Therefore, maintenance of an optimal ratio of efficiency and safety in each individual patient is of particular importance, when the expected benefit (reduction in risk of ischemic stroke and thromboembolic complications in the blood vessels beyond the central nervous system) significantly exceeds the risk of clinically significant bleeding (especially intracranial and major extracranial bleeding). Analysis of data obtained in routine clinical practice (various kinds of registers and databases) allows to evaluate the efficacy and safety of oral anticoagulation in non-valvular AF in a wider range of patients. This approach has significant limitations, including less reliable the procedure of patient selection and analysis of outcomes, and nonrandomized (and usually retrospective) character of comparisons without certainty in the comparability of selected patients by severity criteria that can influence results. In clinical practice, physician makes a choice of oral anticoagulant, and a reason for that selection usually remains unclear. The situation is complicated by the fact that doses used in practice are often different from those studied in controlled clinical trials and recommended for widespread use. All this makes to interpret the results obtained with sufficient care, and to avoid categorical judgments and firm conclusions.

Introduction. A distinctive feature of the Russian population of patients hospitalized with decompensated chronic heart failure (CHF) is the large number of pneumonia identified at the time of admission. Combination of CHF and pneumonia has a significant negative impact on the prognosis of patients, as well as makes difficult of diagnosis and management of patients. Purpose. Evaluation of long-term prognosis of patients with decompensated CHF and pneumonia depending on the clinical characteristics of the patients and the causative agent of pneumonia. Materials and methods. The prospective study included 284 patients with pneumonia against the background of CHF decompensation. All patients had CHF of ischemic etiology, decompensation was confirmed by several symptoms, pneumonia in all patients was verified by chest X-ray, as well as by the presence of clinical signs of lower respiratory tract infection. The mean age of the patients was 72.1±10.1 years; duration of CHF over 5 years - 84.3%, more than 10 years - 15.7%. Clinical, laboratory, and instrumental parameters were assessed; sputum culture for sterility and determination of antibiotic susceptibility was performed; body composition (deficit of lean body mass - LBM)) was assessed; medical history (number of hospitalizations in the previous year, COPD with daily administration of inhaled medications) was registered; and CURB-65, PSI and Charlson comorbidity indices were calculated. Results. The most frequent result of the sputum culture for sterility - revealing the mixed flora (30.3%), with Streptococcus pneumoniae detected only in 22.7% of cases, and there was no microflora in 41.3% of the cases after three times daily sputum collection and culture. Comparison of the clinical characteristics of patients with a 44 variety of results of sputum culture has shown that the patients who had the most severe clinical manifestations referred to the group of mixed infection, the Proteus and Staph. Aureus. Statistically significant (p<0.05) differences among all groups identified in terms of the number of patients with COPD, the LBM deficit. In-hospital mortality was 20.4% (in patients with mixed infection - 40%, with Str. pneumonia - 9,1%); during the six months after hospitalization it reached 50.4%, and 12 months after hospitalization - 62.3% (90.67% - in patients with mixed infection, and only 34.6% in the group Str. pneumonia). Differences in survival in the groups were statistically significant (p<0.05). LBM deficit of more than 10% was detected in 16.2% of patients, LBM deficit of 5-10% - in 25.4% of patients, LBM deficit of less than 5% was detected in 51.1% of patients. In-hospital mortality in patients with LBM deficit of more than 10% was 56.5%, one-year mortality - 100%; in patients without LMB deficit there were no deaths during index hospitalization, one-year mortality was 19.0%. Based on the clinical parameters most significant for the prediction, clinical phenotypes have been proposed, and their prognostic role was evaluated. Combination of mixed infection and LBM deficit more than 5% was revealed in 29.9% of patients; combination of COPD and mixed infection - in 6% of patients; combination of mixed infection, LBM deficit more than 5% and COPD - in 6.3% of patients, of these 2.8% had decreased glomerular filtration rate below 60 mL/min and frequent hospitalization history (more than 2 in the previous year). Various combinations of clinical phenotypes with other results of sputum cultutre were detected less than in 5% of cases. Conclusion. The most poor prognosis for patients with decompensated CHF and pneumonia is associated with the identification of mixed infection in the sputum. Patients in the group with verified mixed infection in the sputum are also characterized by the most severe clinical phenotypes, including frequent hospitalizations, a decrease in LBM more than 5%, and high comorbidity (COPD, decreased GFR less than 60 mL/min).

This article describes the key provisions specified in the guidelines for the management of chronic pain syndrome in palliative care, developed and approved in 2016 by several professional societies.

Diuretics are widely used in the clinic of internal diseases. Loop diuretic torasemide is characterized by high bioavailability and prolonged action, as well as good tolerability without the development of metabolic and electrolyte disturbances. It can be used in the treatment of acute and chronic heart failure, arterial hypertension and chronic kidney disease. The drug not only reduces cardiovascular and sudden mortality, but also reduces the frequency and duration of hospitalizations due to the progression of chronic heart failure, the severity of its clinical manifestations, increases the exercise tolerance, improves the left ventricular diastolic function and the quality of life of patients. All this makes torasemide worthy of wider application when choosing a drug for long-term diuretic therapy in a clinic of internal diseases.

At the end of 2016, the results of the PRECISION study have been published. In this study, 24 081 patients with high cardiovascular risk were receiving celecoxib 200-400 mg/day, naproxen 750-1000 mg/day, or ibuprofen 1800-2400 mg/day for more than 1.5 years (20.3±16.0 months). According to the data received, the frequency of vascular catastrophes (deaths, nonfatal myocardial infarction, and stroke) on the background of use of celecoxib did not exceed the frequency of similar complications when taking control drugs. Furthermore, celecoxib showed a statistically significant benefit in reducing the risk of serious gastrointestinal complications. The new data disproves the concept of «high cardiovascular risk» inherent in all coxibes and confirms the provisions of the national guidelines for the rational use of non-steroidal anti-inflammatory drugs (NSAIDs) published in 2015. This review presents the latest data on the risk of complications with the use of various NSAIDs, including a brief description of the plan and the results of the PRECISION study.

Immunomodulators are drugs that restore the function of the immune system at therapeutic doses. Adaptogens are a group of agents of natural or artificial origin capable of increasing the nonspecific resistance of the organism to a wide range of harmful effects of physical, chemical and biological nature. The effect of adaptogens on the body's systems is determined by their specific structure and set of biologically active chemical components. The main pharmacodynamic features of adaptogens include the stimulation of immunity and the increase of the organism resistance to infections. The review article presents the results of studies on the efficacy of trekrezan, an adaptogenic immunomodulator with complex action. Original domestic drug and biostimulator trekrezan is an immunomodulating agent with pronounced adaptogenic properties. The drug fortifies the immune system of the body, increases the exercise and mental load tolerance, reduces the effect of various toxins, increases the body resistance to hypoxia, low and high temperatures and other unfavorable environmental factors. Trekrezan can be used for treatment, prevention and recovery from colds and flu, to enhance and maintain performance efficiency in asthenic conditions, as well as to help in the adaptation of the organism in new climatic conditions.

Musculoskeletal pain syndromes (PS) are widespread in the population; they are associated with an increase in the number of cases of temporary disability, a decrease in the quality of life of patients, a significant need for taking medications and, accordingly, the risk of development of undesirable side effects of therapy. Modern tactics of management of such patients assumes the decrease in the intensity of PS as early as possible, providing the possibility of expanding the regime of physical exertion and the timely start of rehabilitation measures. The use of muscle relaxants, in particular baclofen, contributes to an increase in the effectiveness of therapy and a reduction in the duration of treatment. The article discusses available data on the effectiveness of this drug in patients with musculoskeletal PS.