卷 29, 编号 4 (2021)

绪论NMDA受体在癫痫发作的发病机制中发挥着特殊的作用，其中一个亚单位由GRIN1基因编码。GRIN1基因的突变已知存在于各种形式的癫痫和脑病患者中。同时，没有关于GRIN1及其多态性参与创伤后癫痫（PTE）发展的数据。

目的：GRIN1基因单核苷酸多态性rs 1126442对创伤后癫痫风险影响的测定。

材料与方法：140例患者中69例为创伤后癫痫，71例为遗传性癫痫（GE）。所有受试者均接受综合检查，评估记忆、神经系统状态、脑电图（EEG）和神经影像学结果，并实时聚合酶链反应对血样进行基因分型。基因研究的对照对象是60名健康个体的静脉血。

结果：在创伤后癫痫患者中，局灶性癫痫转移至双侧强直-阵挛性癫痫发作为主。根据神经影像学资料，发现营养不良、囊性、囊性与神经胶质囊肿及外部性脑积水征象。在脑电图中记录发作间断性和发作性癫痫样活动，以及θ波减速。通过对GRIN1基因rs 1126442多态性进行基因分型，根据共显性遗传模型（OR=3.43; 95% (CI): 1.56—7.55; p=0.0047）、显性遗传（OR=3.24; 95% (CI): 1.57–6.68; p=0.0011）、超显性遗传（OR=2.90; 95% CI: 1.36–6.22; p=0.0048）， 创伤后癫痫患者以G/A杂合型和A/A纯合型为主。 GRIN1基因杂合子基因型G/A rs 1126442的携带与所有癫痫患者脑电图上癫痫样活动的记录有关（OR=2.40; 95% (CI): 1.11—5.20; p=0.024）。

结论：根据显性和共显性遗传模型，携带杂合基因型G/A和纯合基因型A/A rs 1126442 GRIN1与创伤性脑损伤后癫痫的高风险有关，而GRIN1基因杂合基因型G/A rs 1126442的携带与脑电图上癫痫样活动的记录有关。

Introduction: Currently, young Caucasian populations of different generations are living in the Magadan region (MR). The study of heart rate variability (HRV) in these samples will add to the modern understanding of the physiological mechanisms of adaptive restructures in those living in coastal and continental zones of the MR.

Aim: To study restructures of HRV in young Caucasians who were representatives of the zeroth, first, second, and third generations living in the coastal and continental zones of MR, with significant differences in the extremality of natural environmental factors.

Materials and methods: TThe study involved 870 young men aged 17–21 years. HRV parameters were analyzed using a Varikard device.

Results:  Compared with individuals of the same age living in the coastal zone, residents of the continental climatic zone were characterized by more evident predomination of the parasympathetic division of the autonomic nervous system. A tendency to the enhancement of the parasympathetic influence from the zeroth to subsequent generations was observed in both young men living in the coastal and continental zones.

Conclusion: The direction of adaptive shifts in the restructuring of HRV characteristics varied depending on the climatic zone where the examined individuals lived: in the continental climate of the MR, adaptive restructuring of HRV parameters occurs faster and already completed at the first generation in comparison with migrants, with no significant differences between representatives of the first and second generations. In young men living in coastal zones, restructures occur more slowly and continue upto the representatives of the third generation.

Background: To examine the pharmacoepidemiology of treatment for arterial hypertension (AH) in Russia, the PYTHAGOR study has been conducted since 2001, including PYTHAGOR I–II (2001–2002), PYTHAGOR III (2008), and PYTHAGOR IV (2013). Increasing the role of doctors of outpatient care in the pharmacotherapy of patients with AH creates prerequisites for conducting new pharmacoepidemiological studies.

Aim: To investigate the structure of prescriptions of antihypertensive drugs (AHD) by outpatient doctors at the regional level in comparison with the results of PYTHAGOR IV pharmacoepidemiological study.

Materials and methods: In 2018, a survey was conducted in the Voronezh region among 104 doctors, including 58 general practitioners (55.8%), 37 therapists (35.6%), and four cardiologists (3.8%). The average age of the doctors was 45.7 ± 13.5 years, the accumulated period of work was 21.0 ± 13.7 years, and the period of work in an outpatient clinic was 16.6 ± 12.4 years.

Results:  In the structure of doctors’ pREFERENCES in selecting free combinations of AHD, doctors preferred angiotensin-converting enzyme inhibitors (iACE; 90.3%), but they were prescribed more rarely than that in PYTHAGOR IV study (93.8%). The remaining AHD groups were used by doctors of the VR more often than in the PYTHAGOR IV study: beta-adrenoblockers, 89.4% (PYTHAGOR IV, 73.1%); diuretics, 88.4% (73.2%); calcium antagonists (CА), 86.5% (67.3%); angiotensin II receptor blockers (ARB), 81.7% (62.1%); imidazoline receptor agonists, 57.6% (13.3%). In the selection of fixed combinations of AHD: iACE or ARB with a diuretic was used in 71.9% and 36.4%, respectively, and iACE with CA in 46.2%. In the PYTHAGOR IV study, these combinations were used more rarely, i.e., in 33.3%, 28.0%, and 24.1%, respectively.

Conclusion: The data obtained indicate adherence of doctors to modern clinical guidelines for the pharmacotherapy of AH.

论证：与许多其他外科干预一样，在近段或远段植入心脏电刺激器（EX）可能伴随着不利的结果。寻找不良结果的可能危险因素有助于开发有效和安全的方法来管理术后期使用心脏电刺激器的患者。研究植入心脏电刺激器对患者止血系统的影响是目前该领域的研究方向之一。

目的：评估植入双室心脏电刺激器对不同类型慢速心律失常患者止血系统的影响，并确定该组患者不良后果的可能危险因素。

材料与方法：本研究在俄罗斯基础研究基金会资助下，在第19-315-90109号科学项目框架内开展。在一项前瞻性研究（ClinicalTrials.gov ID NCT04499612）中，包括61例患者（男性为45.9%），平均年龄为71.5±8.8岁。手术组包括房室传导阻滞（AB）为23例和窦房结无力综合征（SSS） 为25例，保守组包括房室传导阻滞和窦房结无力综合征为13例，但无心脏电刺激器植入指征。1例房室传导阻滞患者、12例窦房结无力综合征患者、5例保守组患者接受抗凝治疗。其余患者接受抗血小板治疗。测定纤维蛋白原（FI）水平及凝血因子VIII（FVIII）、IX（FIX）、抗凝血酶III （АТ III）、蛋白C活性，对手术组患者于心脏电刺激器植入前及植入后7天行上肢、下肢静脉超声检查及外周血静脉血采集。在C组，只有在研究中才进行类似的检查。

结果：房室传导阻滞患者术后7天血FI水平显著升高（p=0.042）。组间比较发现，手术组植入术后患者AT III活性高于保守组（p=0.018，p=0.006）。术后，窦房结无力综合征患者在抗凝治疗背景下，FVIII和FIX活性低于抗血小板治疗背景下（p=0.048和p=0.015）。根据ROC分析，房室阻滞患者死亡的危险因素是AT III活性降低，窦房结无力综合征患者的FIX活性增加。

结论：在植入心脏电刺激器后至少7天内，房室阻滞患者在抗血小板治疗中止血系统的平衡向高凝状态转移。在窦房结无力综合征患者中使用抗凝剂提供了向低凝的转变。房室传导阻滞患者的AT III活性降低和窦房结无力综合征患者的FIX活性增加是手术后一年内死亡的预后因素。

Introduction: The treatment strategies of patients with stenosis of the left main coronary artery (LMCA) and acute coronary syndrome (ACS) is being debated. One of the key problems is the selection of the optimal time for coronary artery bypass surgery (CABS) in these patients.

Aim: To analyze different periods of revascularization of the myocardium by CABS on a working heart in patients with LMCA stenosis and ACS.

Materials and methods: A prospective analysis of treatment of 112 patients with LMCA stenosis (> 50%) and ACS was performed. Patients were divided to three groups depending on the time of surgical treatment: upto 7 days after occurrence of ACS, 18 (16.1%, group1) patients; 8–14 days, 38 (33.9%, group2) patients; > 14 days, 56 (50%, group3) patients. The average time of ACS-CABS in all patients was 15 days. The groups were comparable in terms of the main preoperative parameters, except for EuroSCORE II and GRACE scale that were predominant in the early periods of CABS.

Results:  LMCA subocclusion (stenosis > 90%) with coexistence of anginal syndrome at rest was observed in more than half of patients with surgery upto 7 days (56%, p=0.019). The surgery duration, blood loss through drains, number of days in the resuscitation unit, duration of artificial lung ventilation, and use of vasopressor support were not significantly different. The revascularization index was higher in surgeries conducted within 7 days than in surgeries performed within 8–14 days (2.33 ± 0.59 versus 1.89 ± 0.65, p=0.02). The evaluation of the dynamics of the functional parameters of the myocardium showed a greater increase in ejection fraction in group1 when compared with group3 after surgery (p=0.036). In the evaluation of the end-diastolic volume of the left ventricle, the average reductions were 16 mL, 14 mL, and 8.5 mL, respectively, without any significant differences among the groups. The rate of intrahospital lethality was highest in group3 (.4%), followed by group2 (2.6%). No fatal outcomes were noted in surgeries conducted in upto 7 days (p> 0.050).

Conclusion: Early CABS performed upto 7 days have similar immediate results to delayed ones and considerably improves the contractile ability of the myocardium in patients with ACS and LMCA stenosis.

论证：放射测量人体内部温度检查（RTM）是乳腺检查的一种实际方法。除了可视化病理病灶外，这种方法还可以评估代谢质量。从确定乳腺癌的生物学亚型和在免疫组织化学分析前评估肿瘤侵袭程度的可能性的角度来看，这是很重要的。

目的：探讨现代RTM在乳腺良、恶性病理鉴别诊断及各种生物学亚型乳腺癌中的应用价值。

材料与方法：我们使用计算机诊断系统RTM 01 RES对118例不同乳腺病理的患者进行了检查。测量在9个点进行：一个控制点在乳腺上观察肿瘤；两个控制点在胸骨上腹部和剑突处；一个控制点在两侧腋窝区以确定可能的转移。研究时间为每位女性15—20分钟。将RTM结果与组织学、超声、乳腺X线摄影及临床影像资料进行比较。

结果：RTM在乳腺病理鉴别诊断中的敏感性为96.9%，准确性为74.5%。RTM鉴别乳腺癌侵袭性亚型和非侵袭性亚型的特异性低，为6.6%。在评估病理组织和正常组织之间的温差时，与未受影响的组织相比，肿瘤组织的温差有增加的趋势。然而，健康乳房和受影响乳房的平均温度在统计上没有显著差异。乳腺癌增殖活性指数与热不对称频率及严重程度无相关性（r<0.3）。

结论：RTM在乳腺组织良恶性改变的鉴别诊断中已被证明是有效的。同时，它也不是评估乳腺癌患病率和生物亚型的首选方法。

Introduction: The coronavirus 2019 (COVID-19) pandemic demonstrated a negative influence on many underlying diseases, their course, and prognosis. A combined course of active tuberculosis, human immunodeficiency virus (HIV) infection, and COVID-19 is a rare case in the routine clinical practice; therefore, it is of scientific and practical interest. In a 41-year-old patient with severe chronic disseminated pulmonary tuberculosis and HIV infection, presence of tuberculosis mycobacteria, resistance to streptomycin and isoniazid, chronic respiratory failure, cachexia, and immunodeficiency, COVID-19 was manifested only by the detection of SARS-Cov-2 virus from the nasopharynx and did not influence the treatment and prognosis of tuberculosis.

Conclusion: The described case of a combination of active tuberculosis with HIV infection and COVID-19 demonstrated that effective treatment of specific tuberculosis process is quite possible.

Introduction: According to the clinical recommendations of the Healthcare Ministry of Russia (2021), uterine artery embolization (UAE) in uterine fibroid is an alternative to surgical treatment in case of high surgical risk and absence of contraindications in women who do not desire pregnancy. The advantages of UAE are associated with lesser blood loss, shorter hospital stay, and recovery of the working capacity. Here, we present an analysis of the literature and our 14-year clinical experience in performing UAE in uterine fibroid. Screening and primary diagnosis of uterine fibroid and indications and contraindications of UAE in the current publications were analyzed. Different methods of EUA implementation were described, and the advantages of the transradial access (TRA) are demonstrated on the basis of the actual clinical experience.

Conclusion: The results obtained in the use of TRA revealed the reduction of radioscopy time and surgery time in general, which are beneficial in terms of the reduction of radiation exposure. Besides, an argument for the given access is a considerably lower frequency of serious complications at the access site. The main obstacles to the introduction and wide use of TRA are based on the lack of specialist experience, absence of specialized training programs, and use of unsuitable and traumatizing instruments. One of the unsolved questions is the absence of an anesthesia protocol, which must be developed with the participation of both gynecologists and specialists on X-ray endovascular diagnostics and treatment.

The article presents previously unpublished documents, comments, and materials that were directly related to significant events in the life and performance of a Russian scientist and academician P. K. Anokhin, such as the Lenin Prize award and the Pavlovian session. The text of P. K. Anokhin’s answer to the review of a corresponding member of the USSR Academy of Sciences E. A. Asratyan of P. K. Anokhin’s monograph “Biology and Neurophysiology of Conditioned Reflex” submitted to the competition for the Lenin Prize, was published. In 1972, P. K. Anokhin was awarded the Lenin Prize for the monograph “Biology and Neurophysiology of Conditioned Reflex”. P. K. Anokhin answered the accusatory statements of the reviewer concerning the “danger” of the functional system for the Pavlovian doctrine and the analytical nature of the scientific method of I. P. Pavlov and answered critical questions about the “synthetic” and “systemic” approach and the priority in the development of the theory of systems and feedback.

The work presented literature facts that the statements and questions of Asratyan were consistent with his accusatory comments about P. K. Anokhin at the Pavlovian session — the scientific session of the USSR Academy of Sciences and of the USSR Academy of Medical Sciences, dedicated to the physiological doctrine of academician I. P. Pavlov, which was held in Moscow in July–August 1950. At the session, P. K. Anokhin was accused of “revision” of the ideological foundations of Pavlov’s teachings and of detraction of the significance of Pavlov’s theory of the higher nervous activity.

After the Pavlovian session, P. K. Anokhin was dismissed from the post of the director of Institute of Physiology of the USSR Academy of Medical Sciences, dismissed from the Presidium of the USSR Academy of Medical Sciences, and appointed Professor of the Department of Physiology of Ryazan Medical Institute. Over the years, E. A. Asratyan persistently criticized P. K. Anokhin as the “opponent of I. PPavlov’s teaching” and actively rejected the theory of functional systems.

Conclusion: The presented documents have not lost their significance even now. These documents are important for understanding the ideological essence of the systemic approach and of the theory of functional systems and are interesting for the history of Russian physiological science and medicine.