Vol 99, No 4 (2018)

Aim. Determination of the influence of age and type of anesthesia on the patient’s cognitive abilities.

Methods. 30 females who underwent surgical intervention were examined. The first group consisted of 14 patients who received general inhalational anesthesia, group 2 included 16 patients who received general inhalational anesthesia in combination with epidural anesthesia. All patients underwent neuropsychological testing at several stages: one day before the surgery, the first day after surgery, on day 28 after the surgery. Cognitive status was assessed using Mini-Mental State Examination (MMSE) and the clock-drawing test (CLOCK).

Results. Given the combination of indices of both types of neuropsychological testing, postoperative cognitive dysfunction was diagnosed when a decrease by 10% or more of both MMSE and clock-drawing test and the MMSE score in patients with diagnosed postoperative cognitive dysfunction was less than 24 on both days 1 and 28. It should be noted that the results of testing before surgery in all groups of patients showed mild cognitive dysfunction. After the surgery, the measures of intellectual ability significantly decreased. The results of the analysis in the early recovery period in the group of patients who underwent combined anesthesia were significantly higher. And in the group of patients with combined anesthesia compared to the group that received only general anesthesia on day 28, cognitive indices were significantly higher: MMSE — pMW=0.041 and CLOCK — pMW

Conclusion. General anesthesia combined with epidural anesthesia affects cognitive function of female patients less negatively than the use of general anesthesia alone.

Aim. To characterize magnetic-resonance imaging manifestations of cerebral small vessel disease in patients in acute period of ischemic stroke and to study their clinical significance.

Methods. 56 patients in acute period of ischemic stroke and 10 subjects without stroke and cognitive impairment were examined. Magnetic-resonance tomography of the brain was performed to all patients and healthy subjects to assess the quantity of lacunes, perivascular spaces, leukoaraiosis and cerebral microbleeds. Based on analysis of 4 neurovisual markers of cerebral small vessel disease, an integral scale was developed. The obtained results were evaluated in association with a wide spectrum of clinical data.

Results. Patients in acute period of ischemic stroke are characterized by higher quantitative expression of certain markers of cerebral small vessel disease in comparison with healthy age-matched subjects. A correlation between neuroimaging markers of cerebral small vessel disease and patients` age, severity and etiology of the stroke was observed. Total expression of cerebral small vessel disease, assessed using the integral score turned out to be higher in the group of stroke than in healthy elderly persons. High rates of certain markers of cerebral small vessel disease and integral scale score are associated with low mobility of patients, neurological deficiency and dependence in daily activities on discharge.

Conclusion. In patients in acute period of ischemic stroke, higher expression of certain markers of cerebral small vessel disease and their total evidence were revealed in comparison with healthy people; total indicator of cerebral small vessel disease expression is associated with neurological and functional outcome of acute period of stroke.

Aim. Comparative assessment of the features of the course of labor and postpartum period in women with obesity of various classes.

Methods. During 2014-2016, a cohort retrospective and prospective study included 318 birth records. The main group consisted of 198 case records of women with different severity of obesity (122 with obesity class I, 57 with class II and 19 with class III), and the control group included 120 case records of women without obesity.

Results. In women with obesity class II and III (p=0.003 and p <0.001) had preterm birth more often than in the control group. Patients with obesity class III had the cesarean section significantly more often than in the control group (p=0.043), in the same group hypertensive disorders in labor and intrauterine hypoxia of the fetus developed more frequently (p=0.009 and p=0.039). In the postpartum period with class III obesity, postpartum haemorrhage was significantly more frequent than in the control group (p=0.045). Among complications of postpartum period in patients with obesity class II, a loychiometer (by 1.7 times), endometritis (by 1.6 times), complications after cesarean section (by 2.1 times) were registered more often than in the control group, and in obesity class III - subinvolution of the uterus (by 2.1 times), endometritis (by 2.4 times), complications after cesarean section (by 3.2 times), divergence of the seams on the perineum (by 2.4 times), but these parameters were not statistically significantly different.

Conclusion. The negative impact of excess body weight on the labor course was shown, moreover, labor in obesity class I is more favorable than in class II and III.

Aim. To study the connection between various dental diseases of inflammatory nature in pregnant women and body weight of newborns depending on the presence or absence of systemic inflammatory reaction in the mother's organism and severity of the main symptoms of periodontal lesions.

Methods. We examined 207 pregnant patients with tooth caries, 72 patients with gingivitis and 93 women with chronic generalized periodontitis, 31 healthy pregnant women with no dental and somatic pathology and no complications of gestational period. The dental status of the patients was studied in the third trimester of pregnancy (36-40 weeks of gestation). Body weight was measured in newborn babies from pregnant women with dental pathology and without it. In peripheral, umbilical and retroplacental blood, the concentration of the inflammatory mediator interleukin-6 was evaluated by enzyme-linked immunosorbent assay, and C-reactive protein was evaluated by latex immune turbidimetry.

Results. The decrease in weight of newborns from mothers suffering from chronic generalized periodontitis, is caused not only by severity of periodontal destruction but also by the course of the disease in pregnancy, damaged integrity and permeability of histochematic barrier, increased concentration of inflammatory mediators in the peripheral, umbilical and retroplacental blood. The risk of having a baby with low birth weight in women suffering from chronic generalized periodontitis with the depth of periodontal pockets is 6 mm, gingival bleeding during probing and increased concentration of systemic inflammatory mediators in peripheral circulation is extremely high and is 0.96.

Conclusion. In mothers suffering from severe gingivitis, moderate chronic generalized periodontitis during pregnancy in case of progressive course of chronic generalized periodontitis, the body weight of newborns is lower compared to body weight of newborns from healthy women without dental pathology.

Aim. Study of the nature and severity of reorganization of the structural elements of gingival epithelium in remission and exacerbation of chronic catarrhal sclerosing gingivitis in patients with β-thalassemia major at the light-microscopic and ultrastructural levels. Methods. From araldite-epon blocks of gingival biopsy specimens taken from 18 patients with β-thalassemia major, the semithin (1-2 μm) and ultrathin (35-70 nm) sections were obtained by means of ultramicrotome. Semi-thin sections were stained by trichrome. Viewing of stained and unstainted ultrathin sections was performed on an electron microscope at an accelerating voltage of 80-120 kV. Results. The increase of ferritin molecules in the intercellular space and in cytoplasm of all cellular elements (except for neutrophils) of the epithelial coverage of the gingiva, as well as the presence of siderophages in the exudative phase demonstrate that one of the main causes of exacerbation of chronic catarrhal sclerosing gingivitis in patients with β-thalassemia major is an increase of congestion of their body with iron-containing elements. The widened slit-like spaces of various shapes and sizes existing in gingival epithelium especially in the acute stage, should be considered as a sign of intercellular edema - spongiosa, and not acantholysis. Disruption of tonofilament-desmosomal complexes of gingival epithelial cells and increased accumulation of glycogen granules in developed hypoxia can be considered the main factors involved in altering the cytodifferentiation of gingival epitheliocytes in the exudative phase of chronic catarrhal sclerosing gingivitis that results in occuring in stratum corneum of light cells without any signs of keratinization, as well as the absence of an epithelial barrier. Conclusion. Identification of molecular mechanisms of disorders of neutrophil and epithelial barriers of gingival mucous membrane can be used in the diagnosis and development of new principles of treatment of inflammatory processes in patients with β-thalassemia major.

Aim. To determine relation between localization, grade of invasion and differentiation in rectal tumor and tumor regression grade after neoadjuvant chemoradiation therapy.

Methods. 88 patients with local advanced rectal cancer (Т2-4N0-2М0) were analyzed: 46 females and 42 males. The average age was 52.4±1.4 years. All patients underwent neoadjuvant chemoradiotherapy. In all groups regardless of tumor localization patients with stage T3 and moderate differentiation grade predominated.

Results. Complete pathological tumor response of grade 4 (TRG4) was revealed in 13 (14.7%) patients, grade 3 (TRG3) in 34 (38.6%) patients, low treatment effect (tumor response grade 2, TRG2) was registered in 26 (29.5%) patients, and lack of treatment effect (grade 1, TRG1) in 15 (17.2%) patients. Analysis of the data from patients with complete or nearly complete tumor regression (grade 3 and 4) demonstrated that such effect of neoadjuvant treatment was most often observed in patients with tumor localized in rectal lower ampulla (58.6%). Among patients with moderately differentiated adenocarcinomas, patients with tumor response of grade 3 and 4 predominated: 28 (56%) patients. According to invasion grade, in all groups patients with therapeutic response grade 3 and 4 prevailed, but most prominently - in groups of patients with stage T4a and T4b - 58.9%.

Conclusion. The closer to anus tumor is located, the more significant effect neoadjuvant therapy has; moderate tumor differentiation grade can be considered as a relative predictive factor of tumor regression on preoperative chemoradiation therapy.

Aim. To study the microhardness of enamel and dentin of deciduous and permanent teeth formed in fluoride-iodine deficiency.

Methods. Enamel and dentin microhardness was examined on sections of 47 deciduous and 43 permanent teeth. Six topographic zones were examined on each tooth section, 24 imprints were performed. Enamel and dentin microhardness was determined on PMT-3M device and by Vicker’s Hardness Test with a load of 50 g for 5 seconds.

Results. Enamel and dentin microhardness of permanent teeth is higher than that of deciduous ones. In the surface layer of enamel the microhardness of permanent teeth is 2.33-2.09 times higher compared to deciduous teeth (in incisors - by 2.24 times, canines - by 2.09 times, molars - by 2.33 times); 2.25-1.94 times higher in the middle layer (in incisors - by 2.17 times, canines - by 1.94 times, molars - by 2.25 times); 2.15-1.89 times higher in the enamel layer at the enamel-dentine junction (in incisors - by 2.15 times, canines - by 1.89 times, molars - by 2.03 times). In the dentin layer at the enamel-dentin junction, dentin microhardness of permanent teeth is 1.90-1.71 times higher than of deciduous ones (in incisors - by 1.78 times, canines - by 1.71 times, molars - by 1.90 times); 2.14-2.0 times higher in the middle dentin layer (in incisors - by 2.08 times, canines - by 2.0 times, in molars - by 2.14 times); 2.05-1.71 times higher in the near-pulp layer (in incisors - by 2.05 times, canines - by 1.71 times, molars - by 1.87 times).

Conclusion. Enamel and dentin microhardness of deciduous and permanent teeth formed in fluoride-iodine deficiency varies considerably; microhardness of hard tissues of permanent teeth is approximately 2 times higher than that of deciduous teeth.

Aim. To determine the presence of lipid and protein peroxidation products in erythrocyte membranes and blood plasma in rats of different ages in an intact state and with developed postinfarction cardiosclerosis.

Methods. In rats aged 4, 12, 24 months postinfarction cardiosclerosis was modeled by coronary occlusion. In blood plasma and erythrocyte membranes, products reacting with thiobarbituric acid and carbonyl derivatives of protein amino acid residues were determined.

Results. In erythrocyte membranes of intact animals aged 12 months, a decrease of the content of thiobarbituric acid-reacting products was revealed in comparison with 4 month-old animals, and in 24 months-old animals the index significantly exceeded the values of young subjects. In the blood plasma of intact animals aged 12 and 24 months, an increased content of thiobarbituric acid-reacting products with respect to rats aged 4 months was revealed. In postinfarction cardiosclerosis, an increase in the accumulation of thiobarbituric acid-reacting products was observed in erythrocyte membranes of 4 and 24 months-old animals. In blood plasma, an increase of this parameter was noted only in the group of 4 months-old animals with postinfarction cardiosclerosis. In erythrocyte membranes of intact rats of all age groups, no differences in the level of carbonyl derivatives of protein amino acid residues were observed, and in blood plasma it significantly increased with age. In 4 and 12 months-old animals with postinfarction cardiosclerosis, significant increase of carbonyl derivatives of protein amino acid residues was mostly pronounced in erythrocyte membranes. In 24 months-old animals with postinfarction cardiosclerosis, this parameter in the membranes and blood plasma was stable.

Conclusion. The intensity of processes of cell membrane and blood lipid peroxidation has pronounced age-dependent features that persist in postinfarction cardiosclerosis; proteins of erythrocyte membranes of intact animals are subject to peroxide modification to a lesser degree than blood plasma proteins; in postinfarction cardiosclerosis formation in 4 and 12 months-old animals, carbonyl derivatives of protein amino acid residues are more intensively accumulated in erythrocyte membranes compared to blood plasma.

Ischemia/reperfusion syndrome is a collective concept that combines various pathological conditions developing against the background of the restoration of the main blood flow in the organ or limb segment, which has long been subjected to ischemia or traumatic amputation. Intensive care physicians often see ischemia/reperfusion syndrome after restoration of blood supply in patients with critical ischemia of the lower limb. The rate of critical ischemia of the lower limbs ranges from 400 to 1000 cases per 1 million of the population. The number of lower limb amputations due to critical lower limb ischemia in economically developed countries is 13.7-32.3 cases per 100,000 of the population. The main etiological factors of critical lower limb ischemia are atherosclerosis of peripheral vessels and vascular complications of diabetes. The pathogenesis of ischemia/reperfusion syndrome is based on a complex of pathophysiological changes resulting from the restoration of blood flow in previously ischemic lower limb. Restoration of blood circulation leads to massive flow into the systemic bloodstream of anaerobic metabolism products, free myoglobin, biologically active substances and inflammatory mediators. The main sources of reperfusion damage are activated forms of oxygen, in particular, superoxide radical О2-, nitric oxide, lipid peroxidation products. In the conditions of primary ischemia, and then tissue reperfusion, excessive production of activated oxygen forms leads to damage of biological structures (lipids, proteins, deoxyribonucleic acid), which causes disruption of normal cell functioning or its death due to necrosis or apoptosis, ion pump dysfunction, adhesion of leukocytes and increased vascular permeability.

The review is devoted to modern understanding of heart failure with mid-range ejection fraction. The formation of the paradigm of «two phenotypes» of heart failure began around the end of the last century. As a result of a number of large epidemiological studies on heart failure with preserved ejection fraction, so-called «grey zone» of ejection fraction values was formed in the range of about 40-50%. This situation arose because of the lack of clearly established level of normal ejection fraction and underlines imperfection of this parameter as the only classification criterion. But no more convenient «tool» for research work was offered. In the past decade, «grey zone» of heart failure has been actively explored by clinical epidemiologists and clinicians. Should we classify these patients as one of the existing phenotypes of heart failure or present them as a new, separate phenotype? Both the first and second decisions require information about the population «portrait» of subgroup, about their response to treatment, and presumptive pathophysiological mechanisms of heart failure. In 2016 European society of cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure, heart failure with mid-range ejection fraction was determined as a separate subgroup to stimulate the search for such data. At the moment mid-range ejection fraction is known to be recorded in about 10-20% of patients with heart failure. They have substantial comorbidities as patients with preserved ejection fraction but the prevalence of ischemic heart disease in this subgroup makes it similar to heart failure with reduced ejection fraction. The response to treatment with beta-blockers and aldosterone antagonists is similar to that of heart failure with reduced ejection fraction. It is important that the mortality rates in all three groups of patients are approximately the same. This circumstance underlines the importance of further searche. Perhaps the research of «grey zone» of the syndrome will help to better understand pathophysiology of the existing heart failure phenotypes and confirm the validity of their identification based on ejection fraction.

Flatfoot is the most common foot disease, the prevalence of which is 30-70% according to many authors. Planovalgus foot deformity asymptomatically existing for a long time can further lead to pain syndrome and limping, sensitivity disorders, trophic disorders, limitation of foot joints mobility, development of arthritic changes with corresponding progression of the function impairment. Timely initiation of treatment, complex pathogenetic and symptomatic therapy as well as strict adherence to the doctor's recommendations help to achieve maximum effect. The aims of treatment of patients with flatfoot are posture stabilization and support of overloaded zones of the plantar surface, improvement of supply of the foot and musculoskeletal apparatus, as well as foot joints, and reduction of pain syndrome. Despite the prevalence of pathology, as well as a wide range of methods of treatment and rehabilitation, conservative treatment does not always lead to a positive result and the problem remains unresolved. This literature review describes the main directions of conservative therapy of patients with flatfoot from the view of evidence-based medicine. The data on the use of special ortheses and orthopedic shoes for correcting the foot deformities are discussed with a description of possible complications. The main forms of exercise therapy used to stabilize the foot muscles tonus, are analyzed. The application of physiotherapeutic factors aimed at improving trophic and blood supply of tissues, as well as strengthening of the musculoskeletal apparatus of the lower legs and feet, is described. Data on the use of complex conservative treatment of patients with flatfoot are presented. The article also focuses on the use of drug therapy as part of the complex treatment.

Aim. Conduction of quantitative and qualitative analysis of registration parameters of medications of two groups - angiotensin converting enzyme inhibitors and angiotensin II receptor blockers in Russian Federation compared to those of leading drug regulators.

Methods. The whole list of currently existing angiotensin converting enzyme inhibitors and angiotensin II receptor blockers according to international Anatomical Therapeutic Chemical Classification of drugs was analyzed by quantitative and qualitative characteristics in four national drug regulators: State drug register of the Russian Federation, American drug regulator - Food and Drug Administration, European Medicines Agency, and Australian drug regulator - Therapeutic Goods Administration.

Results. It was found that by the number of registered international nonproprietary names and by the number of trade names in the group of angiotensin converting enzyme inhibitors the leading position is taken by State drug registry of the RF, and in the group of angiotensin II receptor blockers Therapeutic Goods Administration is leading. On the territory of Russian Federation among angiotensin converting enzyme inhibitors, lisinopril, captopril, perindopril and enalapril are registered in the highest numbers of trade names, and among angiotensin II receptor blockers - losartan and valsartan. The example of the best practice is presented by European Medicines Agency with the lowest number of registered international nonproprietary and trade names. The qualitative analysis of registration parameters of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers (accepted indications) revealed that in RF the highest number of indications for both angiotensin converting enzyme inhibitors and angiotensin II receptor blockers is accepted compared to those of the leading drug regulators. The example of the best practice by this criterion is presented by the European regulator - European Medicines Agency. Based on the understanding that all international nonproprietary names in every analyzed pharmacological group are medications of the «me too» category, the decrease of the number of registration positions by national regulator and thorough analysis of evidence of effects are recommended when approving indications.

Conclusion. In the official state drug registry of RF compared to three foreign drug regulators, the highest number of international nonproprietary names and trade names of angiotensin converting enzyme inhibitors are presented as well as indications for both angiotensin converting enzyme inhibitors and angiotensin II receptor blockers.

Aim. To assess the dynamics of population’s morbidity of type 1 diabetes in different autonomous territorial units of Azerbaijan Republic.

Methods. The unit of observation was a case of type 1 diabetes newly diagnosed during the calendar year. For each administrative territorial unit of Azerbaijan Republic based on the data about quantity of patients with type 1 diabetes and population, morbidity rate per 100 000 of average annual population and average error for calendar years were calculated.

Results. At the beginning of observation (2012) morbidity rate of type 1 diabetes among Azerbaijan population was 54.5±0.76 per 100 000. In different administrative territorial units this indicator ranged between 2.0±1.41 and 294.8±12.0 per 100 000. Relatively low rate of type 1 diabetes was identified in Mingachevir town (2.0±1.41), Masalli (6.1±1.7), Jalilabad (5.8±1.68), Imishli (5.7±2.17), Sheki (4.5±2.17), Gusar (2.2±1.52) regions and Absheron (5.0±1.57 per 100 000). The highest morbidity rate in 2012 was observed in Shamkir (294.8±12.0), Khachmaz (278.7±12.82) and Sabirabad (236.6±11.9 per 100 000). The main trend of difference is a linear decrease of the morbidity rate, which is well explained by linear regression equation (Y=-9.078х+61.1; R2=0.95). In Azerbaijan the average morbidity rate of type 1 diabetes in 2012-2016 was 33.2±0.58 per 100 000, there are administrative territorial units with low (60 per 100 000 in Shirvan city, Sabirabad, Shamkir, Khachmaz districts).

Conclusion. Morbidity rate of type 1 diabetes was different in different calendar years, ratios of the highest and lowest annual morbidity rate in Azerbaijan (3.5) and in separate administrative territorial units (4.2 in Baku, 23.9 in Ganja, 90.0 in Mingechevir, etc.) are different.

List of scientific works of Aleksandr Aleksandrovich Baranov and of Valeriy Yurievich Al’bitskiy of child and neonatal mortality

The article contains description of such serious pathology in emergency surgery as bowel infarction caused by acute mesenteric ischemia in two patients with colorectal cancer admitted to Tatarstan regional clinical cancer center. Patients were admitted for emergency indications with the clinic of an acute abdomen. Both patients underwent an emergency surgery of laparotomy, enterectomy with colon resection and anastomosis. Both patients had satisfactory immediate postoperative results. One patient died 8 months later due to the progression of the underlying disease, the second one is alive to the present day with a satisfactory quality of life and the only complain of frequent loose bowel movements. Most patients with acute mesenteric ischemia are operated on with trial diagnostic laparotomy, and mortality rate for this pathology reaches 90% or more. The presented clinical cases familiarize physicians with an opportunity of successful surgical treatment of patients with acute mesenteric ischemia combined with colon cancer and demonstate expediency and need for surgical interventions with extensive colon resection.

Aim. Comparison of the immediate and long-term results of laparoscopic inguinal hernia repair with and without mesh implant fixation.

Methods. The study included 145 patients over 18 years of both genders with inguinal hernias, including those with relapse after auto-hernioplasty. Patients underwent transabdominal preperitoneal hernioplasty with the application of mesh implant. Patients were randomly divided into two groups matched by age, sex and the type of hernias. In group 1 (n=71) patients underwent laparoscopic hernia repair without fixation, which in case of a direct inguinal hernia was supplemented with transverse fascia endoloop plication; and in group 2 (n=74) - laparoscopic hernioplasty using hernia stapler and/or endocorporal suture.

Results. The duration of surgical intervention in compared groups did not differ significantly (p=0.92), there was no recurrence of hernia in either group. The patients of group 1 had less pain syndrome in the early postoperative period, which was expressed in a significantly lower need for narcotic analgesics in terms of the equivalent amount of morphine (p=0.03) and shorter duration of hospital stay (p=0.5). Advantages of laparoscopic hernioplasty without fixation are the following: (1) intensity of pain syndrome in patients operated by this method is less than in patients operated by the traditional method, during both the first 24 hours after the surgery (p=0.45) and on day 5 (p=0.69); (2) there is no need to purchase foreign-made devices (hernia staplers) and self-locking endoprostheses.

Conclusion. The long-term and immediate results of laparoscopic inguinal hernia repair without mesh implant fixation are not inferior to the traditional methods of implant application; besides, the studied method has a raw of advantages.

Aim. To determine the status and to increase the effectiveness of open surgical treatment of bilateral staghorn nephrolithiasis.

Methods. We studied the results of surgical treatment of 250 patients who underwent open surgery for severe forms of bilateral staghorn nephrolithiasis. The patients were divided into four groups according to the features of changes in both kidneys and ureters - group 1 included 125 (50.0%) patients with bilateral staghorn nephrolithiasis, group 2 - 35 (14.0%) patients with staghorn nephrolithiasis of solitary or the only functioning kidney, 70 (28.0%) patients with unilateral staghorn nephrolithiasis and solitary or multiple kidney or ureter stones on the other side were included into group 3, and group 4 inlcuded 20 (8.0%) patients with unilateral staghorn nephrolithiasis and nonobstructive hydronephrosis and other diseases on the other side. The age of patients ranged from 7 to 76 years old, ranging among children from 7 to 18 years (average age 12.1±0.4 years) and among adults from 19 to 76 years (average age 46.4±0.6 years). Among patients, 121 (48.4%) were males and 129 (51.6%) were females.

Results. Surgical tactics and the results of performed surgeries in certain groups were studied. Overall, 127 (50.8±3.8%) of 250 patients underwent surgery on the right kidney, and 123 (49.2±3.2%) - on the left kidney. To achieve minimal blood loss during the surgery, in 20% of cases renal artery was clamped. To protect kidneys from ischemia, 3 mg/kg of furosemide, 0.2 mg/kg of verapamil and 1 mg/kg of methylethylpiridinol were used before and after clamping of the renal artery. Open surgical treatment of 250 patients with bilateral staghorn nephrolithiasis was successful in 246 (98.4±0.8%) patients. In case of residual stones, extracorporeal or ureterorenoscopic shock wave lithotripsy was performed.

Conclusion. Despite the wide application of modern endoscopic methods of therapy in the treatment of this group of patients, in complex forms of staghorn nephrolithiasis open surgery is more effective.