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Vol 13, No 3 (2022)

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Axiological component in digitalization of health care and medicine

Nesterenko Z.V.


The basis of the modern industrial revolution is digitalization and artificial intelligence due to the influence of the digitalization process on all aspects of the economy, public life, including healthcare and education. The creation of a modernized healthcare system that would meet world standards implies an increase in both the quality and accessibility of medical care, which requires new technological solutions. The development of any new technology relies on digitalization, which has led to the creation of the Internet, robots, and artificial intelligence. Digital health is a new format for the medical industry to improve the efficiency and quality of medical care. The training of modern specialists provides for a significant change in teaching methods. The dependence of the quality of medical education on the multicomponent and increasingly digital nature of social reality is obvious. Additional special training of doctors for remote work is needed, the development of curricula taking into account the digitalization of healthcare. The relevance of the problem of digitalization of higher medical education involves an analysis of the state of modernization processes in medical universities, regulations on the electronic information educational environment of the university, including electronic information and educational resources, a set of information, telecommunication technologies and technological tools. The necessity of systematizing the social effects of the digitalization of higher education and conducting appropriate prolonged studies is substantiated.

Pediatrician (St. Petersburg). 2022;13(3):5-13
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Original studies

The use of stimulation tests for the differential diagnosis of delayed puberty in boys. How to increase the specificity of the method?

Ioffe I.Y., Skorodok Y.L., Plotnikova E.V., Nagornaya I.I., Nagovitsyna K.O., Jelenina L.A.


BACKGROUND: In patients with a constitutional delay of puberty starts and ends completely without any medical intervention. In adolescents with hypogonadotropic hypogonadism puberty is absent or does not continue its development. Differential diagnosis of the conditions is complicated due to lack of standard recommendations for the selection, conducting and assessment of stimulation tests.

AIM: To assess the information content and find ways to increase the specificity of stimulation tests with triptorelin and corionic gonadotropin in relation to hypogonadotropic hypogonadism.

MATERIALS AND METHODS: We examined 44 adolescent boys aged 13.5–17 years with delayed puberty. Sexual development was assessed according to Tanner scale, bone age (X-ray of the non-dominant hand according to the Greulich atlas). All boys were tested with triptorelin. The test with one- and three-day intramuscular injection of human chorionic gonadotropin was performed in 26 and 35 patients, respectively. Statistical analysis was performed using the StatTech v. 2.6.1 (developer — Stattech LLC, Russia). To assess the diagnostic significance of quantitative signs in predicting a certain outcome the ROC-curve analysis was performed.

RESULTS: It was revealed that a negative test with triptorelin was observed in some patients with constitutional delay of puberty. Threshold stimulated luteinizing hormone and follicle stimulating hormone levels were set (8.90 and 5.90 IU/l respectively). Gonadotropins values equal to or lower than selected thresholds allow diagnosing of hypogonadotropic hypogonadism with high sensitivity and specificity. Threshold testosterone levels stimulated by one- and three-day administration of human chorionic gonadotropin were determined (2.11 and 5.84 nmol/l respectively). Testosterone values equal to or lower than selected thresholds allow diagnosing of hypogonadotropic hypogonadism with high sensitivity and specificity. A high degree of positive correlation was found between stimulated luteinizing hormone levels and stimulated testosterone levels during a three-day test with human chorionic gonadotropin.

CONCLUSIONS: A negative test with triptorelin is observed in some patients with constitutional delay of puberty. The specificity of the test can be improved by using threshold stimulated levels of luteinizing hormone and follicle stimulating hormone (8.90 and 5.90 IU/L, respectively). The use of the threshold levels of testosterone (2.11 and 5.84 nmol/l within the one- and three-day functional tests of the testicles respectively) can help to increase the specificity of the considered outdated stimulation tests with human chorionic gonadotropin.

Pediatrician (St. Petersburg). 2022;13(3):15-22
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Influence of extreme factors on the ratio of cardiointervals in the structure of the cardiocycle

Kim A.E., Shustov E.B., Ganapolsky V.P., Zaitseva I.P.


BACKGROUND: The proportion of the golden section, discovered by Pythagoras, is of great importance in the organization of wildlife. Since the golden proportion is one of the criteria for self-organization in living nature, it is natural to assume that this criterion can also be manifested in the work of the heart. The organization of the cardiac cycle is the result of a long evolution of a living organism in the direction of optimizing the structure and functions, ensuring life with minimal energy consumption. However, in clinical medicine and physiological research, until recently, this approach has hardly been used, and there are only a few reports in the literature on the effectiveness of this method.

AIM: To study the sensitivity of indicators of the symmetry analysis of the cardiocycle in accordance with the methodology of the golden section to physical exertion, hypoxic and temperature effects for an integral assessment of the functional state of the heart. For the geometric analysis of the ECG, the ratios of the main parameters were used to assess their compliance with the criteria of the golden section.

MATERIALS AND METHODS: Geometric analysis of ECG interval intervals according to the principles of the golden section in healthy individuals exposed to debilitating physical activity, hypoxia, combined hyperthermia or low temperatures. In the course of the work, the results of a study of 252 male volunteers aged 20–35 years were analyzed, of which 46 people underwent an exhaustive exercise test, 113 a hypoxic test, 34 a combined hyperthermia tolerance test, and 69 a moderate cooling tolerance test.

RESULTS: the use of a geometric analysis of cardiocycles at rest, during exercise, as well as moderate exposure to typical adverse environmental factors (hypoxia, high or low temperatures) showed the fundamental possibility of assessing the dynamics of the functional state in young practically healthy individuals. The indicators characterizing the activity of the processes of regulation of myocardial work at the extracardiac and intracardiac levels were more dynamic. The indicator of symmetry analysis, which characterizes the level of myocardial homeostasis, energy processes and contractility, to a greater extent reflects unfavorable prognostic characteristics in terms of failure of myocardial adaptation. It has been established that for practically healthy individuals (in the normal state of activity, without external influences), the 1st class of the functional state occurs in 83% of cases, hemodynamic stress is noted in 16% of the subjects, hemodynamic inadequacy — in 1%.

CONCLUSIONS: The deviations from the ideal proportion of the golden section identified as a result of adverse external influences remained within acceptable fluctuations, which indicated a fairly perfect functioning of the heart and the cardiovascular system as a whole in the surveyed contingent of young, practically healthy individuals. Proposed by N.V. Dmitrieva (1989) the classification of functional states, based on the assessment of the degree of deviation of the calculated coefficients from the optimal value corresponding to the golden section, is not optimal for healthy young men, which include athletes without signs of “sports heart” and other myocardial pathology. It does not take into account the sign of the deviation, as a result, for the state of rest, with the predominance of bradycardia, typical for athletes, there is an overdiagnosis of tense hemodynamics. At the same time, the work of the heart during short-term intense physical exertion, which naturally causes pronounced sympathicotonia, can be unreasonably characterized as a premorbid or pathological condition.

Pediatrician (St. Petersburg). 2022;13(3):23-35
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Physical therapy in patients with Duchenne muscular dystrophy: dynamics of the course of the disease

Suslov V.M., Lieberman L.N., Suslova G.A., Bure N.P., Adulas E.I., Rudenko D.I.


BACKGROUND: Duchenne muscular dystrophy is the most severe and common form among childhood muscular dystrophies, characterized by a progressive course. One of the main measures to slow down the rate of progression of the disease is physiotherapy, but now there are no recommendations to identify the optimal motor regimen, which is effective and safe for patients with Duchenne muscular dystrophy.

AIM: The aim of the study was to evaluate the effectiveness of regular dynamic aerobic exercise in patients with Duchenne muscular dystrophy who are capable of independent movement.

MATERIALS AND METHODS: We examined 15 patients with genetically confirmed Duchenne muscular dystrophy aged 4,9 to 9,0 years (mean age 6,9 years) who did not participate in rehabilitation programs with exercise therapy for >6 months prior to inclusion in the study. All patients underwent a course of physical therapy, the duration of the course was 4 months, the course was divided into 2 stages: preparatory stage (individual cardiac functional reserve 51–60% with the number of repetitions of each exercise 6–8 times) and training stage (individual cardiac functional reserve 61–70% with the number of repetitions each exercise 10–12 times) The duration of the training was 60 minutes. At the baseline and during dynamic observation after 2 and 4 months, the following were evaluated: 6-minute walk test, timed function test (time to stand from supine, running 10 m, time to climb and descent 4 stairs).

RESULTS: Statistically significant positive dynamics was revealed: the average values of the distance of the 6-minute walk at the baseline were 478,2 ± 10,1 m, then 489,5 ± 11,4 m (p < 0.05) after 2 months and 502,6 ± 10,7 m (p < 0.005) after 4 months. The average values of the time to stand from supine at the baseline was 3,7 ± 0,2 sec., after 2 months — 3,5 ± 0,2 sec. (p < 0.08), after 4 months — 3,5 ± 0,2 sec. (p < 0.05). Mean values of time to run 10 m at baseline 4,3 ± 0,1 sec., after 2 months — 4,1 ± 0,2 sec. (p < 0,05), and after 4 months — 4,1 ± 0,1 sec. (p < 0.005).

CONCLUSIONS: Thus, the regular performance of aerobic physical therapy exercises without weights in combination with training on an exercise bike can increase endurance and speed in ambulant patients with Duchenne muscular dystrophy.

Pediatrician (St. Petersburg). 2022;13(3):37-46
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Immunohistochemical evaluation of apoptosis inducing factor in missed abortion after IVF

Tral T.G., Tolibova G.K., Kogan I.Y.


BACKGROUND: Apoptosis is involved both in the cyclic transformation and the functional activity of the endometrium during the menstrual cycle. Upon the onset of pregnancy, apoptosis is an important component of the placentation process. Moreover, changes in the apoptosis-inducing factor expression in the gravidar endometrium may lead to peculiarity both of trophoblast differentiation and the gestation course, regardless of the conception method.

AIM: to study the expression of apoptosis-inducing factor in abortive material in non-developing pregnancy after IVF.

MATERIALS AND METHODS: Histological and immunohistochemical analysis of the apoptosis-inducing factor expression were performed in 77 gravidar endometrium samples in patients with IVF pregnancy loss at 5–8 weeks and in 15 aborted materials that were received after abortion at similar week progression of pregnancy.

RESULTS: Significant decrease in the expression apoptosis-inducing factor in gravidar endometrium of the control group was revealed in comparison with the same parameter of the main group regardless of gravidar endometrium transformation variation. The highest expression apoptosis-inducing factor was detected in the main group gravidar endometrium that consists secretive and proliferative glands and incomplete gravidar transformation of the stroma.

CONCLUSIONS: High apoptosis-inducing factor expression both in the complete and incomplete gravidar transformation of the endometrium in aborted material after IVF pregnancy loss indicates the pathological apoptosis activation. Thus, the pathological apoptosis initiation occurs even before pregnancy onset in patients with infertility, endometrial dysfunction and chronic inflammatory process in the endometrium.

Pediatrician (St. Petersburg). 2022;13(3):47-53
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Pathophysiology of hepatic insufficiency

Brus T.V., Evgrafov V.A.


The liver is a unique and complex functioning organ, which is central in the metabolism of proteins, carbohydrates, fats and plays an important role in digestion, hematopoiesis, hemocoagulation, and detoxification processes. The pathology of the liver is complex and diverse, often accompanied by the pathology of other organs. Liver diseases are often encountered by doctors of various specialties, and for the clinician, knowledge of this pathology of this organ is essential. Currently, there is a steady increase in the number of patients with liver diseases, mostly people of working age. The development of acute and chronic liver pathology in the vast majority of cases is accompanied by the occurrence of various complications, up to the appearance of liver failure.

The lecture contains up-to-date information about the etiology and pathogenesis of hepatic pathology. Pathological processes in the liver are considered taking into account the complexity of its structural and functional organization. The main symptoms and syndromes of liver pathology are described, their pathophysiological assessment is given. Modern classifications of jaundice, hepatitis, liver failurea regiven.

Pediatrician (St. Petersburg). 2022;13(3):55-64
pages 55-64 views

Clinical observation

Autoamputation of the uterine adnexa due to torsion

Romanova L.A., Rukhlyada N.N., Taits A.N., Malysheva A.A., Dudova K.A.


Uterine adnexa torsion is an urgent surgical condition defined as total or partial twisting of an ovary and/or a fallopian tube on its vascular axis, causing circulatory failure. The diagnosis establishing before the operation is difficult due to absence of pathognomonic features of the clinical picture and instrumental diagnostics. In case of torsion the ovary is usually rotating around the infundibular-pelvic and uterine-ovarian ligaments, which causes vascular compression; ischemia and necrosis are progressing, leading to such complications as pelvithrombophlebitis, bleeding, infections, peritonitis, as well as calcification and autoamputation. Classical clinical picture of the uterine adnexa torsion is a sudden onset of continuous/intermittent pelvic or abdominal pain varying from moderate to severe, diffuse or isolated on one side. Pain syndrome could be of various duration, from several days to several months, and there could be such temporal episodes of pain in past history indicating prior partial torsion. This state can be accompanied by nausea, vomiting, fever, painful and frequent urination. The most precise instrumental diagnostics method in case of uterine adnexa torsion is colour Doppler ultrasonography, however, the final diagnosis is established only during the surgery. If the ovary is ischemic, adnexal detorsion is recommended, in case of necrosis adnexectomy is performed. When examining ultrasound of the pelvic organs, the left ovary is not visualized.

In our clinical case, according to the results of MRI of pelvic organs, the 38-year old patient had a cyst in posterior cul-de-sac with hemorrhagic or high-protein contents, and also the left ovary was not visible. During the laparoscopy an autoamputation of the left uterine adnexa due to torsion was found, as well as presence of necrotizing lesion in posterior cul-de-sac. Thus, laparoscopy is the only reliable method for diagnosing and treating adnexal torsion.

Pediatrician (St. Petersburg). 2022;13(3):65-72
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New coronavirus infection in a child at the age of 2 years 4 months with acute lymphoblastic leukemia (fatal case)

Ivanov D.O., Petrenko Y.V., Reznik V.A., Nasyrov R.A., Timchenko V.N., Pavlova E.B., Pavlova N.V., Bannova S.L., Krasnogorskaya O.L., Kondratyev G.V., Chernova T.M., Shakmaeva M.A., Chepelev A.S., Galichina V.A.


Children get sick less often than adults with a new coronavirus infection (in the Russian Federation, they account for 7.6% of registered cases of COVID-19), with less severe clinical symptoms, they require hospitalization less often, their disease is milder. The frequency of severe and extremely severe cases of COVID-19 in children does not exceed 1%. A clinical case of the course of COVID-19 in a child aged 2 years 4 months is presented. with acute lymphoblastic leukemia. A feature of the presented case is the development of an extremely severe new coronavirus infection in a child with secondary immunodeficiency caused by a long-term course of malignant, treatment-resistant of acute lymphoblastic leukemia. Slow, within 3 months, the development of the infectious process with long-term preservation of normal indicators of the function of the respiratory system led to the formation of viral-bacterial pneumonia with the development of respiratory distress syndrome. Despite the modern complex of therapeutic measures, severe comorbidity led to the development of DIC and multiple organ failure, which was the direct cause of the child’s death. A possible therapy strategy is discussed in a patient with severe comorbidity against the background of secondary immunodeficiency and long-term persistence of SARS-CoV-2 in the presence of IgG antibodies to SARS-CoV-2 in the blood. For the first time, data on morphological changes in the lungs with a long course of COVID-19 (more than 100 days) in a young child are presented.

Pediatrician (St. Petersburg). 2022;13(3):73-82
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Intraventricular hemorrhage in extremely low birth weight infant: a case report

Chepelev A.S., Krasnogorskaya O.L., Fedotova E.P., Galichina V.A., Paneiakh M.B., Sidorova N.A., Nasyrov R.A.


This article focuses on the problem of intraventricular hemorrhage in preterm infants with low and extremely low body weight. Premature newborns are most susceptible to this pathology due to the morpho-functional immaturity of brain tissues and blood vessels. Pathological factors lead to lesion of the vessel wall and a massive hemorrhage in the cavity of the ventricles, sometimes with a breakthrough into the white matter. The morphological findings of hemorrhage in the lateral ventricles of the brain in a child born with extremely low body weight are presented on an example of a clinical case. The article presents a description of the morphology of damage to the germinal matrix and choroid plexus as one of the most common sources of hemorrhage. The main attention is paid to the state of the blood vessels: arterioles, venules, capillaries. Possible causes and consequences of vascular injury in the periventricular region are indicated here. According to the recent studies, intraventricular hemorrhage appears more often due to damage to the choroid plexus in children born at 37 weeks of gestation and later. In this report we consider the problem of hemorrhage from the reducing germinal matrix’s vessels into the subependymal region with spreading into the white matter and lateral ventricles.

Pediatrician (St. Petersburg). 2022;13(3):83-88
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The structure of practical classes on human anatomy for foreign students studying at St. Petersburg State Pediatric Medical University in English

Zimina M.A., Karelina N.R., Khisamutdinova A.R., Artyukh L.Y.


Human anatomy is a fundamental discipline in the system of medical education, it creates the basis for the subsequent effective study of clinical disciplines. The experience of teaching the discipline to students studying in English is invaluable. The description of approaches, structures and methods of overcoming difficulties during classes with foreign students in the discipline «Human Anatomy» is unique, and has no analogues in domestic and foreign literature.

To analyze the conditions of teaching foreign students of 1–2 courses in English at the St. Petersburg State Pediatric Medical University.

The experience of teaching human anatomy in English, the peculiarities of interaction with foreign students in the pedagogical process are described, the possible causes of their mistakes, failures and emotional reactions are indicated. The structure (plan) of practical classes and the specifics of teaching human anatomy to foreign students in English are described in detail. The approaches used at each stage of the practical training on the course “Human Anatomy” in groups of foreign students studying in English are described.

Our experience shows that it is most effective to conduct a practical lesson in accordance with the following scheme: (1) the teacher needs to devote more time to organizational and disciplinary issues, especially at the beginning of training (first semester); (2) verification of the written homework is carried out before the start of the oral survey on the previous topic; (3) to consolidate the acquired knowledge, an oral survey is conducted only after a detailed analysis with the whole group of homework; (4) during the explanation of a new topic, the teacher constantly refers to the text of the textbook, the demonstration of images is made sequentially, the description of the drawings correlates with the text of the textbook, and only after that the teacher draws a diagram (organ, vessel). The demonstration of dummies and anatomical preparations is the final stage of explaining the new material; (5) the teacher discusses the homework and the requirements for its implementation. In our opinion, it is mandatory to write a brief summary in accordance with the plan of the topic being studied when doing homework.

This form of practical training involves the repetition of both the studied material at the stage of testing students’ knowledge, and new information obtained in the process of explanation. At all stages of the practical lesson, the volume of individual work with each student of the group increases, which ensures the effectiveness of the lesson as a whole.

Changing the structure of the practical lesson helps foreign students studying in English at the Department of Human Anatomy of St. Petersburg State Pediatric Medical University to overcome language barriers and orient themselves in educational materials based on the principle of descriptive systemic anatomy. This approach gradually forms students’ skills of independent study of biomedical disciplines and is more effective.

Pediatrician (St. Petersburg). 2022;13(3):89-101
pages 89-101 views

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