No 3 (2018)

The Russian Scientific Medical Society of Internal Medicine (RSMSIM), being a full member of the European Federation of Internal Medicine, takes part in the global campaign «Choosing Wisely». The concept of the campaign implies promoting the rational distribution and increasing the efficiency of the use of health care resources. Recognizing the importance of this initiative, the leading foreign medical professional societies supported it, joining their efforts to improve the quality and safety of healthcare. Each participating professional community created a list of clinical situations (recommendations) that should be considered in terms of rationalizing therapeutic and diagnostic approaches. The resulting lists stimulate discussion about the appropriateness of many frequently applied interventions. The aim was to identify a list of top-5 recommendations of the Russian Choosing Wisely campaign. Methodology and results. At the first stage, all the recommendations published in other campaigns of internal medicine societies, have been screened by the working group and 90 recommendations the most relevant to clinical practice in the field of internal medicine in Russian, were retrieved. As a second step, a group of experts evaluated the rating of the selected items. Then 26 items that received the highest score, as well as 4 items, additionally proposed by the experts, were submitted for online voting to the RSMSIM full members for the rating evaluation. As for the attribution of priority, the delegates could express their opinion intuitively, without request for justifications. After a four-month voting period, experts evaluated the evidence base for 10 situations with the maximum score and developed a coordinated position. Conclusion. Thus, the top-5 list of Russian Choosing Wisely Campaign, supposed to be discussed by professional therapeutic community, was finally identified. The future build-in studies will show whether campaign will be followed by physicians and whether following the recommendations will lead to a reduction in morbidity and mortality, as well as a reduction of financial waste in the Healthcare. The campaign can be a useful tool for inducing therapists and subspecialists to a different way of thinking about professionalism and appropriateness of interventions.

The aim of the study was to show the modern possibilities of diagnostics of multifocal lesions of the mucosa of the digestive tract against the background of the use of non-steroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents (АТА) and to present a new classification of mucosal lesions and the possibility of its application for further transition to clinical recommendations as a guide to action. Materials and methods. In order to develop an algorithm for managing patients receiving NSAIDs and anti-thrombotic therapy, as well as classification of lesions of the mucosa of the digestive tract, against the background of the treatment, we used the experience of foreign colleagues and information resources: PubMed, Cochrane Library, DynaMed, Google Scholar, TRIP Database , which today is the most comprehensive in terms of coverage by the public meta-search system, which has an advanced document sorting system, existing normative documents, as well as own experience. The algorythm for management of patients cured with NSAIDs or АТА included assessment of the patient's condition before the start of treatment, dynamic monitoring of complications based on clinical and laboratory data, endoscopic diagnostic data, and a decision support system in the form of the Russian classification of esophagogastroduodenoenterocolatopathy. Results. The developed Moscow classification of multifocal lesions of the mucosa of the digestive tract with nonsteroidal anti-inflammatory and antithrombotic agents is presented in the form of a cascade that includes a common scale, an expanded (specifying) scale, and a stratification of the risks of recurrence of bleeding and thromboembolic complications. Conclusion. The proposed Moscow classification of lesions of the mucosa of the digestive tract with non-steroidal anti-inflammatory drugs and drugs for lowering blood clotting (L.B. Lazebnik, G.V. Belova) is a testament to the medicine of «Three P» - personified, preventive and predictive, accounting for a significant number of gender, anamnesis, functional and clinical-laboratory indicators. The application of the Russian classification refers to the decision-support system for the tactics of conducting an extremely complex category of patients with severe comorbid pathology.

Aim. To evaluate the effect of renal artery stenosis on the risk of cardiovascular events in patients with acute coronary syndrome. Materials and methods. The study included 323 patients with acute coronary syndrome: 217 (67,1%) men and 106 (32,9%) women. The mean age of the patients was 59,6±9,2 years. Results. Atherosclerotic renal artery stenosis, together with the ejection fraction volume, left atrial size, right ventricle size, interventricular septal thickness, influenced on risk of developing non-fatal cardiovascular events. The increase in AGFR after coronary angiography increased cardiovascular risk as well. Conclusions. The developed model for predicting the risk of fatal and non-fatal cardiovascular events can be widely used in a comprehensive examination of patients with acute coronary syndrome and atherosclerotic renal artery stenosis.

Objective. To study the role of cartilage glycoprotein-39 in patients with gonarthrosis in combination with cardiac ischemia, arterial hypertension and dyslipidemia, depending on inflammatory changes in joints, radiographic stage, severity of pain syndrome and degree of functional insufficiency of the joints. Material and methods. 110 patients with gonarthrosis in combination with cardiac ischemia, arterial hypertension and dyslipidemia were included in the study in the rheumatological department of NOSMA. Clinical parameters of gonarthrosis were evaluated and the concentration of cartilage glycoprotein-39, CRP, ESR and lipid spectrum was measured in serum. Results. A significant increase of cartilage glycoprotein-39 was revealed in all OA patients. The highest level of cartilage glycoprotein-39 was revealed in patients with radiographic stage III, especially if there was a reactive synovitis. There was significant correlation between the cartilage glycoprotein-39 and clinical parameters of gonarthrosis, CRP, ESR, cholesterol, CA. Conclusion. Our study of the level of cartilage glycoprotein-39, CRP, lipid spectrum indicated the presence of an inflammatory process, which is an important part of the pathogenesis of osteoarthritis and atherosclerosis.

The possibility of achieving atopic bronchial asthma of moderate severity, comorbid with allergic rhinitis and atopic dermatitis due to the inclusion of allergen-specific immunotherapy with combined basic anti-inflammatory therapy is considered in the article.

The aim was to study the contribution of the novel markers to the prediction of thromboembolic complications (TE) in patients with non-valvular atrial fibrillation (AF). Material and methods. The objects of the cohort prospective study were 102 patients with non-valvular AF and 0-2 additional clinical risk factors, except female gender (CHA2DS2-VASc score ≤2 in men and ≤ 3 in women). Special methods of investigation included the genotyping of the polymorphisms: G(-455) A of the fibrinogen B gene (FBG), G10976A - the factor VII gene (FVII), the C807T- the integrin a2gene (ITGα2), the T1565C-the integrin β3 gene (ITGβ3)and the C3550T- the glycoprotein gene Iba (GPIbα), determination of plasma concentration of VIIand XII coagulation factors and plasma fibrinogen level. The follow-up period was 36 months. Endpoints were ischemic stroke, transient ischemic attack, or systemic TE. Results. Endpoints were registered in 14 (13,7%) patients: ischemic stroke - in 13 (92,9%) cases, transient ischemic attack - in one patient (7,1%). Three (21,4%) adverse events occurred during the first year, 5 (35,7%) - during the second year and 6 (42,9%) - during the third year of follow-up. In patients with one additional risk factor (RF) while being enrolled into the study, the actual frequency of TE complications during the follow-up period exceeded the expected frequency by 3,1 times, in patients with two RF - by 3,7 times. Patients of the combined group of GA+AA genotype of the FGB gene were more likely to reach endpoints than patients with the GG genotype (64,2% vs. 35,7%, x2=9,5, p=0,006, OR 4,3 (95% CI 1,6-11,8)). Patients with genotypes TT and CT+TT of the ITGα2 gene reached endpoints more often than homozygous carriers of the wild allele. The plasma level of fibrinogen was significantly higher in patients of the combined group of GA+AA genotypes than in GG group of FGB gene (2,8 (2,4-2,9) g/l vs. 2,5 (2,3-2,6) g/l, p=0,002). Besides, there was a trend to a higher plasma fibrinogen concentration 101 in the group of patients with adverse events in comparison with those without (2,7 (2,45-3,03) g/l vs. 2,51 (2,3-2,8) g/l, p=0,087). According to the results of a three-year observation, a prognostic model including a number of novel predictors (atrial fibrillation duration, the presence of coronary heart disease, the size of the left atrium, the plasma level of fibrinogen and the presence of the polymorphic allele 807T of the ITGα2 gene), appeared to be highly informative and specific in prediction of TE complications in patients with non-valvular AF. Conclusion. The allele (-455)A of the FGB gene, as well as the CTand TT genotypes of the polymorphic marker C807Tof the ITGα2 gene, are associated with thromboembolic complications in patients with non-valvular atrial fibrillation. The prognostic model, developed on the basis of a complex of few clinical, laboratory and non-modifiable genetic biomarkers, demonstrated high reliability in predicting the actual number of thromboembolic complications in patients with non-valvular atrial fibrillation and 0-2 additional clinical risk factors, except female gender (CHA2DS2-VASc score ≤2 in men and ≤3 in women) during 3 years follow-up. The model seems to be promising for individualizing of the risk of thromboembolic complications and may provide improved decision support in terms of treatment and prevention strategy in patients with AF.

Objectives: to investigate correlation between electrolyte imbalance at admission and long-term prognosis. Material and methods: the research based on the data of physical examination, laboratory and instrumental investigation of 111 consecutive patients hospitalized for decompensated heart failure (HF), III-IV functional class NYHA. Results: Mean age 71±12 years; 44,1% were males; 64,0% had emergency admission (IV functional class NYHA), mean left ventricular ejection fraction 41±15%. Electrolyte imbalance at admission was presented in 33,3% of patients. Multivariable survival analysis revealed 2,33-fold independently increased relative risk of all-cause mortality for the patients with electrolyte imbalance at admission [HR 2,33; 95% CI 1,19-7,70; p=0,0201]. Conclusion: in patients hospitalized for decompensated HF, electrolyte imbalance at admission is a predictor of unfavorable prognosis and increased a year mortality.

Aim of the research work. A cough is one of the most discomforting symptoms in patients with acute respiratory infections. The management of a cough requires constant improvement of therapeutic approaches and selection of drugs with optimal efficacy and safety balance and their combinations that can be used in everyday clinical practice. The All-Russian Non-Interventional Observational Program for the Study of Rengalin in the Outpatient Management of Cough (REAL) was conducted to investigate the outpatient practice of cough management with the use of the combined release-active preparations Rengalin. Material and methods. The program comprised 34 920 patients. The study population was represented by children (47,4%) and adults (43,6%) (9,0% of patients had no age recorded) diagnosed with acute respiratory infection accompanied by a cough for no more than three days before presenting to medical attention. The patients received Rengalin either as monotherapy or as a part of complex therapy with regimens and treatment duration determined by the attending physician. Results. Both children and adults showed a reduction in the severity of a cough and improvement in auscultation findings on average within 3 ± 1 day of treatment. A dry cough turned into a wet cough by the 4th day of treatment regardless of patients' age; dry or wet cough became residual on the 6th day of treatment. In 64.8% of adult patients and 31.3% of children, dry cough resolved or turned into a residual cough bypassing the phase of a productive cough. The program showed a low incidence of any adverse events in patients taking Rengalin (0,3%). The findings of our study suggest that the combined Rengalin preparation could be used in outpatient settings by both internists and pediatricians in the management of a cough associated with acute respiratory infections.