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Vol 12, No 2 (2020)

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Indications for referring patients with gastrointestinal pathology to the bureau of medical and social examination (to help a practitioner)
Stolov S.V., Ugleva E.M., Yamshikova T.Y., Makarova O.V., Bakulina N.V.

When examining citizens at federal state medical and social examination institutions when recognizing a person as disabled, it is necessary to apply the criteria for determining disability set forth in Order of the Ministry of Labor of Russia dated August 27, 2019 No. 585н. The conditions for recognizing a citizen as a disabled person are persistent violations of body functions, which lead to a restriction in various categories of life, the need for social support. Certain clauses of the Order regulate the examination of citizens with diseases of the gastrointestinal tract. The article sets out generally accepted criteria for assessing the activity of the disease, the main research methods that allow to determine violations of the function of the digestive organs for timely and reasonable referral for examination at the bureau of medical and social examination.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):5-16
Adaptogens: modern realities and prospects for the search of new effective and safe medicines (review of literature and authors’ research)
Nekrasa I.A., Bibik E.Y., Frolov K.A., Dotsenko V.V., Krivokolysko S.G.

In present medical practice adaptogens and antihypoxants are a promising, but still insufficiently studied group of medicines. The largest evidence base among plant adaptogens was developed for ginseng, aralia, eleutherococcus, lemongrass, rhodiola, leuzea, sterculia. Antihypoxants, like trimetazidine, meldonium, succinic and γ-aminobutyric acid medications are included in the clinical guidelines. They have the most pronounced antihypoxic effects in a variety of diseases and pathological conditions, accompanied by impaired energy metabolism in the tissues. But their effect is not always high due to the variety of etiological factors causing hypoxia.

Tetrahydropyrido[2,1-b][1,3,5]thiadiazine derivatives characterized by various pharmacodynamic effects with low toxicity which opens up prospects for a detailed further study. In animal experiments, the most pronounced adaptogenic and antidepressant effects is exerted by compounds TD-0348 and TD-0479, superior in strength to the antihypoxants used in modern clinical practice, the classic plant adaptogen ginseng.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):17-26
Original researches
Current, effectiveness of therapy and outcomes of new coronavirus infection: preliminary analysis
Sayganov S.A., Mazurov V.I., Bakulin I.G., Lataria E.L., Artyushkin S.A., Chizhova O.Y., Ruslyakova I.A., Prokofieva N.A., Fil T.S., Tsurtsumiya D.B., Tikhonov S.V., Skalinskaya M.I., Rasmagina I.A., Alieva M.K., Trofimov E.A., Bakulina N.V., Kolmakova E.V., Sheyko A.D., Belousova L.N.

Relevance. Verification of a new coronavirus infection (COVID-19) requires clear algorithms for the diagnosis and treatment of patients, depending on clinical, laboratory and instrumental dates. Timely and informed decisions on optimizing management tactics and prescribing proactive anti-inflammatory therapy before development of a complete symptom complex life threatening conditions are needed in some cases.

Aim of the study. To analyze the course and outcomes of a new coronavirus infection, depending on the initial characteristics of the patients and treatment options.

Materials and methods. A preliminary analysis of the case histories of 129 people hospitalized in the center for treating patients with a new coronavirus infection at North-Western State Medical University n.a. I.I. Mechnikov was made by random sampling. Among the hospitalized patients there were 67 men (51.9%), the average age was 57.9 ± 16.4 years, 62 women (48.1%), and the average age was 60.2 ± 13.6 years. During hospitalization, all patients underwent standard clinical laboratory and instrumental examination, as well as determination of saturation (SpO2), markers of the cytokine storm (CRP, ferritin, AST, D-dimer, fibrinogen, lymphocytes), compute tomography (CT) of the lungs. The effectiveness and safety of therapy was evaluated by the outcome (recovery, death), as well as by the presence of adverse events in the background of the therapy. Statistical processing of the research results was carried out using the Statistica 12 for Windows application software package, the significance of differences between the two relative values was evaluated using the Student t-test (t > 2, p < 0.05).

Results. Fatal outcomes were significantly more frequently recorded among patients of older age groups and males. The presence of concomitant diseases such as obesity, diabetes mellitus, pathology of the cardiovascular system was accompanied by more frequent fatal outcomes. That allows considering comorbidity as a risk factor for severe course and poor prognosis of COVID-19. However, in general, in the presence of the indicated forms of concomitant diseases, it was not possible to establish significant differences with the outcomes of COVID-19, which may be due to an insufficient amount of patients. Predictors of fatal outcome was low values of saturation, the presence of respiratory failure, a significant amount of lung tissue damage (CT-3-4), as well as high values of CRP, ferritin, AST, D-dimer, neutrophilia, lymphopenia, thrombocytopenia. The use of anticytokine drugs (ACD) in complex therapy can be considered a favorable predictor of outcome, which indicates the advisability of wider use. The materials of the study allow not only a preliminary assessment of the course and effectiveness of complex therapy using anticytokine drugs with COVID-19 in patients with comorbid diseases, but also to develop therapeutic and diagnostic algorithms in patients of this category.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):27-38
Natriuretic response to hypervolemia and injection of diuretics in patients with chronic heart failure
Frolov D.S., Shustov S.B., Sveklina T.S., Sardinov R.T., Saluhov V.V.

Relevance. The article analyze the results of changes in the diuretic and natriuretic response to standard hypervolemic load and the injection of a diuretic in patients with chronic heart failure with preserved and reduced left ventricular ejection fraction.

Purpose. Evaluation of changes in the natriuretic response to hypervolemia and diuretic injection in patients with chronic heart failure.

Materials and methods. 25 men with chronic heart failure were examined; the average age was 68 y. o. (67; 73). Of these, 13 patients with chronic heart failure and a left ventricular ejection fraction (LVEF) of less than 50 % entered the first studied group and 12 patients with chronic heart failure with preserved LVEF (more than 50%), who entered the second studied group. In all the patients, hypervolemia was induced by Ringer’s solution, followed by the injection of furosemide and the registration of diuresis and natriuresis.

Results. When analyzing natriuresis in the studied patients, it was found that at the same concentration of serum sodium, there is a multidirectional reaction to the excretion of sodium in the urine in both groups. At the same time, the rates of diuresis in both groups did not differ significantly.

Conclusion. Thus, with chronic heart failure and reduced LVF less than 50% patients had a lower natriuresis compared to those studied with preserved LVF. In the patients with chronic heart failure fluid overload on the mixed response it is noted that if the urine sodium level is at the lower limit of normal in patients with reduced LVF less than 50%, then, against the background of stimulation of diuresis, sodium begins to be excreted more intensively. In the patients with chronic heart failure with preserved LVF, the urine sodium level is at the upper limit of the norm and when furosemide is stimulated, there is a decrease in its excretion.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):39-44
Experience of surgical treatment of vertebral artery injuries
Glushkov N.I., Rylkov V.F., Sementsov K.V., Skorodumov A.V., Moiseev A.A., Alekseev V.V., Koshelev T.E., Votinova A.O.

The aim of the study was to analyze the results of spinal artery damage treatment of the injured.

Materials and methods. An 2-year analysis of treating 7 patients with vertebral artery injuries admitted to the City Hospital (GB) No. 26 of St. Petersburg was carried out. The problems of diagnosing and treating these injuries have been identified. The solutions to these problems have been suggested. Two clinical cases of successful treatment of injured patients with spinal artery damage have been presented.

Results. There’s a possibility of damaging vertebral arteries in neck injuries thus defining the need for introducing high-informative methods of inspection (a spiral computer tomography contrast angiography, a Magnetic Resonance Imaging) and low-invasive (X-ray endovascular) interventions in urgent surgery. The implementation of complex instrumental examinations, their nature, the number of them and urgency should be determined by a surgeon individually considering the recommendations of related specialists.

Conclusions. Regardless of the wound size and the patient’s condition, examination and treatment of patients with neck injuries should be carried out in large hospitals with angiosurgeon and other narrow specialists in the panel of doctors with the 24-hour surveillance, as well as access to full examination and high-tech urgent operational interventions.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):45-50
Application of rhythmic transcranial magnetic stimulation with low-intensive running pulsed magnetic field in the rehabilitation of patients with post-stroke cognitive impairment syndrome
Tereshin A.Е., Kiryanova V.V., Reshetnik D.A., Karyagina M.V., Savelyeva E.K., Efimova M.Y.

The purpose of the investigation was to study the nootropic effects of rhythmic transcranial magnetic stimulation (rTMS) using low-intensity magnetic field with the induction rate of 45 mT, base frequency of 50 Hz, modulation frequency of 10 Hz in combination with standard medical and psychological therapy in the rehabilitation of patients with post-stroke cognitive impairment (PSCI).

Materials and methods. The rehabilitation outcomes in 98 patients with PSCI syndrome were studied. The patients were subdivided into 2 groups: 53 patients of the control group were treated with the standard nootropic medications and neuropsychological procedures; 45 patients of the main group were additionally treated with rTMS by the low-intensive running pulsed magnetic field of 10 Hz modulation frequency. The dynamics of the score increase according to Rivermid, Karnovsky, Roshina, MMSE, mRS, HDRS, SF-36 scales were analyzed.

Conclusion. Application of rTMS with low-intensive running pulsed magnetic field of 10 Hz modulation frequency in combination with a standard program of cognitive rehabilitation contributes to a significant improvement in the recovery of mental calculation function in ischemic stroke patients, as well as normalization in mood swings in the patients who had suffered a hemorrhagic stroke and post-stroke depression. This variant of rTMS can be safely used in patients with PSCI syndrome in the early recovery period, 3 weeks after the onset of stroke.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):51-62
Risk factors for cardiovascular complications in patients with left breast cancer in daily clinical practice
Poroshina E.G., Vologdina I.V., Zhabina R.M., Stanzhevsky A.A., Krasilnikova L.A.

Purpose. Detection of adherence to a healthy lifestyle (HLS) and evaluation of behavioral risk factors for cardiovascular complications (CVC), including psychosocial, in patients with left breast cancer at the stage of chemoradiotherapy in daily clinical practice.

Materials and methods. The patients were hospitalized for 3D conformal radiation therapy on the bed of the left breast with a total radiation dose (TRD) of 39 Gy (equivalent to 48 Gy of conventional fractionation). All the patients had a Madden mastectomy at the previous stages followed by doxorubicin therapy at a cumulative dose not exceeding 360 mg/m2. Determination of all components of a healthy lifestyle was carried out according to the data of interviewing the participants. The risk category of cardiovascular complications was assessed according to the SCORE scale. Additional characteristics including psychosocial factors were assessed. The examination included ECG and echocardiography.

Results. At the initial examination, 58% of middle-aged patients and 74% of elderly patients showed comorbidity, while 18% of middle-aged patients and 29% of elderly patients had multiple comorbidities. Low adherence to healthy lifestyle in the patients was primarily associated with low physical activity due to the existing pain syndrome caused by both the tumor process itself and the surgical intervention. Physical activity in both groups was significantly lower than in the general population. High risk of CVC was significantly more common in the elderly patients. Systolic and diastolic dysfunction as a manifestation of cardiotoxicity after the previous stage of doxorubicin therapy were detected in middle-aged patients in 35.7% of the cases, in the elderly patients in 56.5% of the cases (HR 0.643, 95% CI 0.470-0.880). Psychosocial factors such as acute chronic stress and family problems were the most common. All the examined patients showed moderate reactive anxiety. The elderly patients showed a high level of personal anxiety.

Conclusions. The obtained data suggest that in breast cancer patients, low adherence to HLS is primarily associated with low physical activity and ‘unhealthy diet’ and to a much lesser extent smoking, which is of great importance in the formation of a healthy lifestyle in these patients in the future. In elderly patients, the study significantly more often identified risk factors such as obesity, high blood pressure, hypercholesterolemia and hyperglycemia. These patients revealed increased level of personal anxiety. This highlights the need for an expanded study of not only the main but also additional risk factors.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):63-70
On the participation of eosinophils in tissue recovery after a local cold injury
Shagrov L.L., Shutsky N.A., Kashutin S.L., Nikolaev V.I., Malyavskaya S.I.

The article studies the correlation of the content of peripheral blood and red bone marrow eosinophils with the level of secretion of fibroblast growth factor (FGF-21), insulin-like factor (IGF-1) and vasculoendothelial growth factor (VEGF-C) in blood serum during the formation of dermal collagen after local cold damage. Animals of the experimental group after the onset of narcotic sleep on the depilated skin of the back were simulated contact frostbite of the 3rd degree. On the 3rd, 7th, 14th and 21st day of the experiment, the concentrations of growth factors, % dermal collagen content, and also the content of eosinophils in peripheral blood and red bone marrow were determined in the blood serum. The research results showed that the development of eosinopenia after a local cold injury occurs due to the sequestration of eosinophils in the affected area. The presence of reactive changes after a local cold injury not only in peripheral blood, but also in the red bone marrow may indicate the participation of eosinophils in tissue repair processes after a local cold injury.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):71-78
Case report
Choledocholithiasis as a cause of obstructive jaundice after pancreatoduodenal resection
Zemlyanoy V.P., Sigua B.V., Gurzhii D.V., Kurkov A.A., Safonova M.A., Zakharov E.A., Fetisov K.V.

Obstructive jaundice is one of the main symptoms of diseases of hepatobiopancreatoduodenal region organs and occurs in 12.0-45.2% of cases. The article describes a clinical case of successful treatment of a patient with choledocholithiasis that occurred three years after gastropancreatoduodenal resection performed for pancreatic head cancer. Patients often die before they develop long-term postoperative complications, among which we can distinguish cicatricial strictures of biliodigestive anastomosis, which occur in 0.8% of cases, and the development of obstructive jaundice, which is primarily characteristic of the progression of the underlying disease or relapse. While analyzing the literature, we didn’t find any statistically significant data regarding the incidence of gallstone disease (cholelithiasis) as a cause of obstructive jaundice in the patients after pancreatoduodenal resection. Thus, the clinical case presented below is of particular interest.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):79-84
Diagnostic difficulties and features of endovideosurgical treatment of a patient with mucocele of the appendix
Sigua B.V., Zemlyanoy V.P., Lataria E.L., Kurkov A.A., Melnikov V.A., Vinnichuk S.A.

The mucocele of the appendix is the expansion of the appendix with the accumulation of a large amount of mucus. The mechanism and causes of mucocele are not fully understood. According to some authors, such changes in the appendix can occur due to cicatricial narrowing of the lumen of the appendix, compression or blockage of its base. Other authors believe that the mucocele of the appendix is a benign tumor that develops from the remnants of primitive mesenchyme and is sometimes prone to malignancy. Clinical manifestations of mucocele of the appendix are nonspecific. In a number of patients, this disease causes pain in the right abdomen, more often pulling, intermittent. However, the disease is often asymptomatic. In this regard, diagnosis is established only during performing an operation, most often, regarding acute appendicitis. Nevertheless, instrumental diagnostic methods such as ultrasound and computed tomography of the abdominal and pelvic organs make it possible to suspect mucocele. Despite the frequent asymptomatic, non-aggressive course, a number of life-threatening complications can become the outcome of the mucocele of the vermiform appendix. The most formidable complication is the rupture of the appendix with mucus entering free abdominal cavity, followed by the development of peritoneal pseudomyxoma due to implantation of mucus-forming cells. The only option for radical treatment of the mucocele of the appendix is a surgical intervention. A presented clinical case demonstrates the difficulties of diagnosis, as well as the features of surgical treatment of a patient with a mucocele of the appendix.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(2):85-90

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