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№ 3 (2018)
- Жылы: 2018
- Мақалалар: 15
- URL: https://journals.eco-vector.com/2412-4036/issue/view/6748
Articles
Choosing wisely: doing more does not mean doing better
Аннотация
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.
Therapy. 2018;(3):4-11
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Diagnosis and rational therapy of painful diabetic peripheral neuropathy (Interdisciplinary consensus of experts based on results the expert meeting on January 23, 2013, Moscow)
Аннотация
EXPERT GROUP FOR PREPARATION OF RECOMMENDATIONS: chairpersons of expert group: academician of RAS Melnichenko G.A., academician of RAS Yachno N.N., academician of RAS Martynov A.I. responsible executors: professor G.R. Galstyan, professor E.G. Starostina, professor I.V. Gurjeva, MD A.Ju. Tokmakova, PhD M.V. Churjukanov. Members of the expert group: G.A. Melnichenko - deputy director of «Endocrinology scientific center» Federal State Budgetary Educational Institution, director of the Institute of clinical endocrinology, chairman of Moscow association of endocrinologists, vice president of Russian association of endocrinologists, academician of RAS, professor, M.D.; M.V. Shestakova - deputy director for scientific work of «Endocrinology scientific center» Federal State Budgetary Educational Institution, director of Institute of diabetes,academician of RAS, professor, MD; N.N. Yachno - professor of the Department of nervous diseases of general medicine faculty, director of scientific-educational clinical center of neurology of I.M. Sechenov First Moscow State Medical University, president of Russian pain studies society, academician of RAS, professor, MD; A.I. Martynov - professor of the Department of hospital therapy № 1 of general medicine faculty of A.I. Yevdokimov Moscow state university of medicine and dentistry, president of Russian scientific medical society of therapists, academician of RAS, professor, MD; G.R. Galstyan - head of the Department of diabetic foot, chief research worker of «Endocrinology scientific center» Federal State Budgetary Educational Institution, professor, MD; E.G. Starostina - professor of the Department of endocrinology of M.F. Vladimirsky Moscow Regional Scientific-Research Clinical Institute, professor, MD; II.V. Gurjeva - professor of the Department of endocrinology of general medicine faculty of of Additional post-graduate training state budgetary institution of Russian medical academy of continious professional education, head of medical social expertise and rehabilitation sector in case of endocrinous diseases of Federal State Budgetary Educational Institution Federal buro of medical social expertise of Ministry of Labour of Russia, professor, MD; M.L. Kukushkin - head of the laboratory of fundamental and applied pain problems of research institute of general pathology and pathophysiology of RAS, executive secretary of Russian society for pain studies, professor, MD; M.V. Chjurjukanov - associate professor of the Department of nervous diseases of general medicine faculty of I.M. Sechenov First Moscow State Medical University, PhD; I.A. Strokov - associate professor of the Department of nervous diseases of general medicine faculty of ГМ. Sechenov First Moscow State Medical University, PhD; AJu. Tokmakova - chief research worker of diabetic foot Department of «Endocrinological scientific center» Federal state budgetary educational institution, MD.
Therapy. 2018;(3):12-38
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Systematizing classification of multifocal lesions of gastrointestinal mucosa caused by non-steroidal antiinflammatory and antithrombotic agents (Moscow Classification)
Аннотация
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.
Therapy. 2018;(3):40-52
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Risk factors for the development of obstructive shock in patients with pulmonary embolism
Аннотация
Obstructive shock (OS) is one of the most often cause of death in patients with pulmonary embolism (PE). Aim: We aimed to investigate the clinical, anamnestic, laboratory and instrumental predictors of OS development in patients with PE; to investigate effectiveness of previously proposed ROCky score as predictor of OS in patients of intermediate risk. Methods: 121 patients with confirmed PE of high and intermediate risk were enrolled. PE was confirmed by CT angiography and/or echocardiography. In 29 patients (24%) OS developed during 30 days of observation, 92 patients (76%) had favourable course. Clinical, anamnestic, laboratory, instrumental parameters were investigated. ROCky score threshold to identify the patients with high risk of OS was s3,5 points. Results: Predictors of OS in PE-patients were: chronic heart failure (p=0,01), diabetes mellitus (p=0,0001 ), atrial fibrillation (p=0004), permanent risk factor of venous thromboembolism (VTE), (p=0,001), syncope (p=0,02), positive heart type fatty acid binding protein (hFABP) test (p=0,00001), heart rate (HR) И 10 bpm (p=0,003), systolic blood pressure (SBP) ≤100 mmHg (p=0,00001), creatinine clearance ≤70 ml/min (p=0,0005). The ROCky score demonstrated strong effectiveness as a predictor of OS during 30 days (p<0,001, CI 95% 2,5-30, sensitivity 73%, specificity 83%). Conclusions: The risk factors of OS in Pe patients are: chronic heart failure, atrial fibrillation, diabetes mellitus, permanent risk factor of VTE, syncope, positive hFABP test, tachycardia, hypotension, creatinine clearance ≤70 ml/min. In retrospective analysis, the ROCky score demonstrates strong prediction value of OS development in hemodynamically stable patients with PE and may be recommended for applying in clinical practice.
Therapy. 2018;(3):53-59
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The effect of renal artery stenosis in combination with other risk factors on fatal and nonfatal vascular events in patients with ACS
Аннотация
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.
Therapy. 2018;(3):60-65
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Metabolically healthy obesity - focus on endothelium and inflammation
Аннотация
The aim of the study was to evaluate the relationship of adipokines with markers of subclinical inflammation and endothelial dysfunction in patients with metabolic healthy obesity (MHO). Material and methods: our study included 50 persons aged of 25-50 years with obesity in the absence of metabolic disorders (IDF criteria, 2005, marked as MHO), the control group consisted of 50 healthy respondents without obesity. We investigated clinical and biochemical parameters, HOMA-IR index, levels of leptin, resistin, adiponectin, CRP-hs, TNFα, IL6, VEGF, endothelin-1 (ET-1), von Willebrand factor (VWF) in patients under study. Results: in MHO patients, independently of NOMA-IR index, there was an increase of leptin, resistin, VEGF, and IL6 levels. The concentration of CRP-hs and TNF-α was increased in MHO group with HOMA-IR ≥2.7 was increased. Systolic blood pressure correlated with leptin level (r=0,43, p<0,05), TNF-α (r=0,44; p<0,05) and IL6 (r=0,33; p<0,05); diastolic blood pressure - with leptin level (r=0,35, p<0,05). Links between high density lipoproteins and leptin (r=-0,55 and r=-0,60; p<0,01), resistin (r=0,32; p<0,05 and r=0,60; p<0,01) and VEGF (r=-0,70, p<0,01) were established. The VeGf level correlated with HOMA-IR (г=0,62; p<0,01), leptin (r=0,29; p<0,05), resistin (r=0,70; p<0,01), IL6 (r=0,74, p<0,01) and ET-1 (r=0,29; p<0,05). Conclusion: Obese patients without metabolic disorders, having normotension and normal insulin sensitivity, are less influenced to adverse cardiovascular risks due to less expressed hormonal and inflammatory activation of adipose tissue and, as a result, less pronounced endothelial dysfunction. While insulin resistance develops, cardiovascular risk increases due to activation of subclinical inflammation and angiogenic endothelial dysfunction.
Therapy. 2018;(3):66-71
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The role of cartilaginous glycoprotein-39 in patients with knee osteoarthritis with concomitant coronary heart disease, arterial hypertension and dyslipidemia of unclear genesis - a multidisciplinary problem
Аннотация
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.
Therapy. 2018;(3):72-77
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Fever of unknown origin - a multidisciplinary problem
Аннотация
The term «Fever of unknown origin» corresponds to a situation in clinical practice in which a long-lasting fever is the leading or the only sign of a disease that remains unrecognized during a routine examination. Difficulties in establishing the correct diagnosis are due to the presence of a large number of diseases occurring with a febrile syndrome, which are combined into four groups: generalized or local infectious and inflammatory processes, malignancy, systemic diseases (connective tissue diffuse diseases, vasculitis), other diseases (pathology of the intestine, endocrine organs, etc.). Such a variety of etiological factors dictates the participation in the diagnostic process of representatives of various medical professions - internists, cardiologists, rheumatologists, oncologists and, if necessary, other specialists. A clinical example illustrates the difficulty of diagnosing a disease that occurs with the syndrome of prolonged hyperthermia.
Therapy. 2018;(3):78-84
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Feasibility of achieving control of comorbid atopic bronchial asthma
Аннотация
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.
Therapy. 2018;(3):85-90
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Quality of life in patients with acute coronary syndrome and behavioral activity types A, AB and B
Аннотация
The aim. To study the effect of behavioural activity on quality of life (QE) in patients with acute coronary syndrome (ACS). Material and methods. The study included 100 patients with ACS, which were subsequently divided into groups in accordance with the underlying disease - acute myocardial infarction (AMI) and unstable angina (UA). The age of patients from 40 to 75 years, the therapy is standard according to the underlying disease. Life quality indicators were assessed at all stages of the study. Results. In patients with ACS and type B behavior, the quality of life is significantly higher than in patients with type A. The physical and psychological components of health in patients with type B are also significantly higher than in patients with type A. The behavioral type of activity A is one of the risk factors of cardiovascular diseases (CVD), including ACS. Conclusion. The behavioral type of activity affects the physical and psychoemotional state of patients with ACS. In patients with ACS and type B behavioral activity, the physical and psychoemotional state is higher than in patients with type A behavior. Behavioral activity type A is a factor that may potentially adversely affects the course and prognosis of ACS.
Therapy. 2018;(3):91-99
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New possibilities for personalizing prognosis in patients with nonvalvular atrial fibrillation
Аннотация
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.
Therapy. 2018;(3):100-107
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Evaluating processes of cardiac remodeling in the development of chronic thromboembolic pulmonary hypertension
Аннотация
The aim. To evaluate the processes of remodeling of the right and left heart in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Material and methods. The study included 30 patients who underwent in-patient examination and treatment at the State Clinical Hospital №1 named after N.I. Pirogov, Moscow, to confirm the diagnosis of CTEPH and the selection of drug therapy. For all patients, one expert performed an echocardiographic (EchoCG) study to evaluate the parameters of the right and left parts of the heart. Results. Statistically significant correlations between the severity of CTEPH flow and the structural and functional parameters of the right and left parts of the heart were obtained. Conclusions. The evaluation of structural and functional echocardiographic parameters of cardiac remodeling in patients with CTEPH was performed. Correlation links between severity of the disease course and echocardiographic data are revealed, which allows a simple, non-invasive method to conduct dynamic observation of patients and to identify prognostically unfavorable factors of CTEPH course.
Therapy. 2018;(3):108-112
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Disturbances of water and electrolyte homeostasis as a predictor of an unfavorable long-term prognosis in patients hospitalized for decompensated CHF
Аннотация
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.
Therapy. 2018;(3):113-124
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A heart fatty acid binding protein the diagnosis and prognosis of acute coronary syndrome: new possibilities or lost illusions
Аннотация
The article discusses the current situation with the diagnostic and prognostic value of evaluation of heart type fatty acids binding protein (hFABP), a marker of damage and necrosis of myocardium, in patients with suspected acute coronary syndrome (ACS). The data of comparison of hFABP with currently more common biomarkers is provided. The possibilities of a multimarker approach, including the evaluation of hFABP, for the diagnosis or exclusion of various forms of ACS is analyzing. Special attention is paid to the Russian experience of application of point of care express-tests for the qualitative detection of hFABP in inpatient and outpatient medical care. The obtained high characteristics of such tests allow to recommend it for more wide application in clinical practice, especially in the early periods of ACS. Further studies will more accurately determine the value of hFABP in the diagnosis and prognosis of ACS.
Therapy. 2018;(3):125-133
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The results of the All-Russian Observational Program for the Study of Rengalin in Outpatient Management of Cough (REAL)
Аннотация
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.
Therapy. 2018;(3):134-143
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