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Vol 12, No 4 (2020)

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Reviews
Current approaches to surgical treatment of pancreatic head cancer
Kabanov M.Y., Glushkov N.I., Sementsov K.V., Skorodumov A.V., Alekseev V.V., Savchenkov D.K., Mulendeev S.V., Koshelev T.E., Belikova M.Y., Votinova A.O.
Abstract

Pancreatic cancer accounts for 8–10% of all cases of malignant tumors of the digestive organs and 50–60% — of pancreaticoduodenal malignant neoplasms. Over the past 30 years the incidence of pancreatic cancer in Russia has increased by 30%. The main method of treatment this category of patients requires surgical intervention. Extensive experience has been gained in using various types of surgical therapy. The review analyzes the results of modern studies on the efficacy and safety of the most common of them.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):5-13
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Original researches
Possibilities of janus kinase inhibitors application in complex treatment of patients with COVID-19
Saiganov S.A., Mazurov V.I., Melnikov E.S., Latariia E.L.
Abstract

Introduction. More than 30 million cases and more than 970 thousand fatalities from COVID-19 have been registered. The effectiveness of interleukin-6 and interleukin-1 antagonists and janus kinase inhibitors in the treatment of new coronavirus infection is still being analyzed. At present, the emphasis is placed on the introduction into a wide practice of a Russian vaccine named Sputnik V.

Purpose. To compare the effect of complex therapy with baricitinib and dexamethasone on the course of COVID-19 interstitial pneumonia.

Materials and methods. A retrospective analysis of the medical records of 122 people hospitalized at the North-Western State Medical University named after I.I. Mechnikov was carried out. All the patients were divided into three groups: the first one — 64 patients who received therapy including baricitinib; the second one — 33 patients whose therapy included dexamethasone; the third one — 25 patients in the comparison group.

Results. In the first group of patients the lung damage was 25-75% (2-3 degree CT) in 78.1% of the patients, more than 75% in 14.1% of the patients, which was accompanied by severe clinical symptomatology and high laboratory activity. Against the background of the tharapy, positive dynamics of CT was observed in 48.4% of the cases. In the second group of patients the volume of pulmonary tissue damage by CT of 2-3 degrees was observed in 84.9% of the examined patients, clinical and laboratory activity corresponded to the moderate course of the disease. Against the background of the complex therapy, positive dynamics according to CT examination was observed in 18.2% of the cases. In the comparison group, positive dynamics according to CT was observed in 56% of the patients against the background of the therapy. Normalization of clinical and laboratory parameters was observed in all the patients from three study groups on the background of treatment.

Conclusions. In the first group the majority of the patients had he highest number of comorbid pathologies and severe course of COVID-19. Normalization of clinical and laboratory parameters was observed in all the groups of patients. As a result of standard comprehensive therapy, as well as therapy involving baricitinib or dexamethasone, positive dynamics according to CT data was observed in 48.4%, 18.2% and 56% of the patients, respectively.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):15-24
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The effect of stem cells on the functional state of liver tissue against the background of a liver cirrhosis model (experimental study)
Kotkas I.Е., Mazurov V.I.
Abstract

Relevance. Treatment of liver cirrhosis is an extremely important problem of modern medicine. Improvement of liver function in this category of patients is important not only for hepatology, but also for surgery, since surgical interventions on the liver in this pathology are often accompanied by the development of liver failure.

Purpose. To evaluate the effect of cell therapy on liver function in the experiment.

Materials and methods. The article presents the results of the experimental use of use of stem cells in simulated liver cirrhosis. The experiment was performed on 132 female c57black mice, which were between 12 and 18 weeks old. After forming a model of liver cirrhosis, in order to assess the effect of cell therapy on the function of liver tissue, individuals were injected with stem cells through the vessels of the peripheral bed and intraportally. 30 days after cell therapy, the blood levels of ALT, AST, alkaline phosphatase, plasma diene conjugants, plasma malondialdehyde, plasma superoxide dismutase, and glutathione peroxidase were evaluated.

Conclusion. According to the findings, obtained in the experiment, the use of cell therapy against the background of simulated cirrhosis of the liver contributed to a decrease in the severity of cytolytic and cholestatic syndromes, stimulation of liver protein function, suppression of free radical oxidation and stimulation of the antioxidant system. At the same time, the best effect was achieved when the cell structures were introduced not into the peripheral vessels, but directly into the vascular bed of the liver.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):25-32
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Rehabilitation treatment in patients with cerebral stroke
Tertyshnaya N.M., Goldobin V.V., Klocheva E.G., Lobzina A.S., Agbaii G.G., Artsimovich V.V.
Abstract

Introduction. Treatment and rehabilitation of ischemic stroke patients is an important medical and social problem.

The purpose of the study is to compare effectiveness of different complex rehabilitation methods for improving patient functional abilities and social adaptation.

Materials and methods. 114 patients, aged 61.1 ± 10.7 years, in early and late rehabilitation period of ischemic stroke were examined. Group I (n = 73, age 63.2 ± 10.9) was represented by the patients that received conventional rehabilitation treatment ambulatory or in neurological department with additional biological feedback; patients of group II (n = 41, aged 60.4 ± 10.3) received ambulatory conventional rehabilitation treatment.

Results. There was no significant difference in the patients’ age of groups I and II. The most frequent stroke location in the middle cerebral artery in the II group patients was in the right hemisphere (p < 0.05). The improvement of damaged function was revealed in both groups. Clinical scale data on discharge indicated more severe manifestations in the I group patients. In the main group, the restriction of daily activity in women was more pronounced than in men (p < 0.05).

Conclusions. Rehabilitation treatment in post-stroke patients led to functional improvement. Clinical manifestations in the patients that require rehabilitation in hospital, were more severe in comparison with ambulatory rehabilitated group. Data on more pronounced disturbances in activities of daily living in women compared to men require further study.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):33-38
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Epidemiology and prevention of coronavirus infection in long-term care facilities
Sevastianov M.A., Bozhkov I.A., Luchkevich V.S., Khorkova O.V., Vladimirova O.N.
Abstract

The authors have analyzed the main trends in the spread of coronavirus infection among elderly and senile people living in long-term care institutions, both in the Russian Federation and abroad. Possible anti-epidemic measures aimed at preventing the spread of coronavirus infection among the least socially protected segments of the population, including those living in residential care facilities were considered. Using the example of one of the stationary social service institutions in St. Petersburg, the article presents an effective model of reducing the existing risks of the formation of an epidemiological focus among elderly residents during the pandemic.

According to WHO data from April 23, 2020, up to half of the deaths from coronavirus in Europe occur in nursing homes. Boarding Home for the Disabled and Elderly No. 1 (BHDE No. 1) is one of the largest general care institutions in the metropolis. The contingent of BHDE No. 1 is made up of persons with pronounced or significantly pronounced limitations of the ability to self-service and movement, the average age of which is about 69 years. More than 90% of the residents have disability groups I and II and comorbid pathology of the cardiovascular, respiratory and other systems. Palliative care (nursing care) is needed for about 30% of social service recipients. In order to prevent the spread of SARS-CoV-2 in BHDE No. 1, not only “standard” quarantine measures were taken, but also “alternative” management decisions. As a result, within the period of 8 months in 2020, no cases of coronavirus infection among residents were registered in BHDE No. 1. Management decisions on the organization of the provision of social and medical services to the residents of BHDE No. 1 have shown their high efficiency and can be used in case of repeated deterioration of the epidemiological situation.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):39-46
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Modern aspects of surgical treatment of patients with adhesive small bowel obstruction
Sigua B.V., Zemlyanoy V.P., Petrov S.V., Qalandarova D.H.
Abstract

Despite the ongoing preventive measures aimed at reducing the formation of adhesions in the abdominal cavity with an increase in the number of surgical interventions on the abdominal organs, the number of patients admitted to surgical hospitals with adhesions of the small intestine is also increasing. It should be noted that annually about 1–2% of previously operated patients undergo treatment in surgical departments while the exceptional fact is that 50–70% are patients with acute adhesive ileus of the small intestine and the mortality rate in this group ranges from 13 to 55%. In recent years the literature has been actively discussing the advantages of minimally invasive technologies in the treatment of adhesive small bowel obstruction since the use of traditional methods often leads to the development of complications with repeated (in 60% of cases) surgical interventions. The purpose of this study was the development and implementation of an improved therapeutic and diagnostic algorithm in patients with adhesive small bowel obstruction which made it possible to improve the results of treatment. A comparative analysis of 338 patients with adhesive small bowel obstruction who were treated in the surgical departments of the St. Elizabeth Hospital in St. Petersburg in the period from 2016-2019 was carried out. All the patients were divided into 2 groups: the main (I) group (2018-2019), which consisted of 198 patients who received the improved diagnostic and treatment algorithm as well as the comparison group (II) (2016-2017) which included 140 cases — these are patients examined according to the standard protocol and operated on in the traditional way. Moreover, in 98 cases, it was possible to resolve acute adhesive small intestinal obstruction in a conservative way, and 240 patients underwent surgical treatment. The developed diagnostic algorithm is based on the consistent application of the most informative diagnostic methods. At the same time the indications and the sequence of their application were established which ultimately made it possible to shorten the preoperative time interval as well as to determine the optimal treatment strategy with the choice of the type of surgical treatment (laparotomy or laparoscopy). The proposed treatment and diagnostic algorithm allowed to reduce the complication rate from 46.5% (53) to 22.2% (28) (р < 0,001), and the mortality rate from 14.9% (17) to 3.9% (5) (p < 0,01).

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):47-54
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Comparative analysis of the effectiveness of antiangiogenic therapy and vitrectomy in the treatment of diabetic macular edema occurring against the background of the vitreoretinal interface pathology
Boiko E.V., Oskanov D.H., Sosnovskii S.V.
Abstract

Background. Diabetic macular edema is a specific complication of diabetes. Antiangiogenic therapy is an effective treatment for diabetic macular edema. Another manifestation of diabetic retinal damage is a change in the vitreoretinal interface. There is evidence of the effectiveness of vitrectomy in the treatment of other ophthalmic diseases with pathology of vitreoretinal interface.

Purpose. Comparative analysis of the effectiveness of antiangiogenic therapy and vitrectomy in the treatment of diabetic macular edema occurring against the background of the vitreoretinal interface pathology.

Materials and methods. The study involved 60 patients (60 eyes) with diabetic macular edema accompanied by vitreoretinal interface pathology. The patients were divided into 2 groups: group 1 — 30 eyes, which received antiangiogenic therapy with intravitreal injections of ranibizumab; group 2 — 30 eyes, on which vitrectomy was performed with removal of the internal limiting membrane. The observation period was 12 months.

Results. In group 1, a significant increase in visual acuity was obtained 1 month after the intravitreal injections. During the observation and performing, if necessary, intravitreal injections, visual acuity decreased and by 12 months did not statistically differ from the initial one. In group 2, there was a gradual reliable increase in the visual acuity.

A decrease in retinal thickness in the second group was significantly greater by the end of the study.

The average number of intravitreal injections required during the observation in the first group was significantly greater than in the second group.

Conclusions. In the patients with diabetic macular edema against the background of pathology of the vitreoretinal interface, vitrectomy led to a significant increase in visual acuity by 12 months of observation, in contrast to the patients receiving antiangiogenic therapy only. In the patients with diabetic macular edema and pathology of the vitreoretinal interface, complex treatment (antiangiogenic therapy + vitrectomy) led to a significant decrease in the thickness of the retina and the number of injections of angiogenesis inhibitors.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):55-60
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Possibilities of diagnostic scales in patients with acute appendicitis in the conditions of an infectious hospital
Zemlyanoy V.P., Melnikov V.A., Nahumov M.M., Letina Y.V., Zemlyanskaya A.Y.
Abstract

Currently, diagnostic scales are being actively developed to help doctors diagnose and make decisions regarding the treatment tactics of certain diseases. In particular, there are diagnostic scales for acute appendicitis. However, we found no publications describing the results of assessing the sensitivity of diagnostic scales for acute appendicitis in relation to patients admitted to infectious diseases hospitals, as well as the results of comparing the sensitivity of these scales in patients in general surgery and infectious diseases hospitals. Thus, based on the sufficient clinical material, we have analyzed the results of comparing the sensitivity of some diagnostic scales of acute appendicitis in relation to patients in general surgical hospitals and patients being treated in hospitals with an infectious profile. The results of the study show that the sensitivity of diagnostic scales in relation to acute appendicitis in patients treated in infectious diseases wards is lower than in patients in surgical departments of the general profile. The following result may be explained by “masked” course of acute appendicitis (when “simulating” the symptoms of acute intestinal infection), as well as the blurred clinical picture of acute appendicitis in patients with acute and chronic infectious diseases.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):61-66
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Antibacterial therapy of endometritis after cesarian section: optimizing the dosing regime
Korobkov N.A., Bakulina N.V., Repina M.A.
Abstract

Purpose. To study the pharmacokinetics of β-lactam antibiotics in the development of endometritis after cesarean section to select the optimal dosage regimen.

Methods. A prospective, randomized, single-center study included 52 women in puerperas with endometritis after a caesarean section, divided into four groups. The patients of the first group (n = 17) received a course of ceftriaxone bolus in a single dose of 2.0 g (n = 10) and in the mode of prolonged perioperative infusion (n = 7). The patients of the second group (n = 10) received cefepim bolus at a dose of 2.0 g 2 times a day (n = 5) and in the extended infusion mode (n = 5). The patients of the third group (n = 14) received amoxicillin / clavulanic acid (Amoxiclav® 1000 mg + 200 mg) bolus at a dose of 1.0 g 3 times a day (n = 7) and in the extended infusion regimen (n = 7). The patients of the fourth group (n = 11) received ampicillin / sulbactam (Ampisid® 1000 mg + 500 mg) bolus at a dose of 1.0 g 4 times a day (n = 6) and in the extended infusion regimen (n = 5). We have compared the concentration of the studied antibiotics in the uterine cavity in the four groups using high performance liquid chromatography.

Results. The effective bactericidal concentration (C > 4×MIC) was not maintained throughout the entire dose interval in any of the treatment groups. The clinical efficacy and safety of the studied antibiotic regimens were similar. However, prolonged infusion of cefepime and aminopenicillins provided significantly higher concentrations in lochia.

Conclusion. Prolonged intravenous infusion of cefepime, ceftriaxone, amoxicillin / clavulanic acid and ampicillin / sulbactam in the treatment of endometritis after a caesarean section improves the pharmacokinetic / pharmacodynamic characteristics of these β-lactams in the uterine cavity, compared with the traditional bolus administration.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):67-72
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Case report
The experience of using dark-field microscopy to assess damage to the endothelial glycocalyx in rheumatoid arthritis
Vlasov T.D., Shimanski D.A., Nesterovich I.I., Trophimov V.I.
Abstract

Rheumatoid arthritis is the most common inflammatory joint disease and one of the most common chronic inflammatory diseases. The leading role in the pathogenesis of rheumatoid arthritis is the damage to the endothelial glycocalyx — a thin dynamic layer of macromolecules located on the surface of the endothelium and consisting of proteoglycans, glycoproteins and glycosaminoglycans, which contributes to the maintenance of rheumatoid arthritis activity. Therefore, early detection of violations of the vasculr endothelium condition, especially the endothelial glycocalyx, will identify a group of patients with a poor prognosis. In this context, the method of dark-field microscopy may be promising. It allows non-invasive and in vivo assessment of the thickness of the sublingual endothelial glycocalyx, which will make it possible to search for new unconventional risk factors for the unfavorable course of rheumatoid arthritis and cardiovascular risk in these patients, as well as personalize treatment by developing a complex of preventive and therapeutic measures aimed at restoring endothelial function, reducing the risk of cardiovascular complications, disability and mortality from rheumatoid arthritis. The unique capabilities of this research method are demonstrated by the example of the clinical case.

HERALD of North-Western State Medical University named after I.I. Mechnikov. 2020;12(4):73-80
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