卷 16, 编号 3 (2024)

Patients suffering from rheumatic diseases are at high risk of the development and accelerated progression of cardiovascular due to inflammation as one of the etiological factors of atherogenesis and heart failure. To choose the rational and safe treatment, especially in comorbid patients, it is necessary to have a comprehensive and complete understanding of the mechanisms of these relationships, as well as the most accurate determination of cardiovascular risk using modern validated scales. The first part of the review presents the results of current experimental and clinical studies on the effect of the chronic inflammatory and its biomarkers on the development, course and prognosis of cardiovascular diseases.

BACKGROUND: In recent decades, there has been a widespread increase in the incidence of diverticular disease by more than 10 times and an increase in the frequency of its complications in the range from 5 to 25%.

AIM: To present the clinical experience of implementing the classification of acute diverticulitis according to E.J. Hinchey (1978) modified by A.M. Kaiser (2005).

MATERIALS AND METHODS: The srudy considered the hospitalizations of 314 patients with complicated diverticulitis; the patients were divided according to the Hinchey’s classification into 6 groups depending on the complications.

RESULTS: This classification allows not only to stage the disease depending on the severity of the complications, but also to verify these complications with the results of X-ray computed tomography. The modern methods of their correction, which were applied in the Republican Clinical Hospital (Kazan), are given.

CONCLUSIONS: The widespread use of the classification by therapists, surgeons, coloproctologists, and emergency doctors will ensure timely and effective treatment tactics, predict the dynamics of the inflammatory process, and manage the flow of patients with this pathology.

BACKGROUND: Solute and water transport by peritoneal membrane has significant variation between patients; the function changes significantly over time. This affects treatment outcomes and requires individual approaches.

AIM: To evaluate the influence of the baseline peritoneal transport state, its dynamics during peritoneal dialysis and the possibility of long-term outcomes modification.

MATERIALS AND METHODS: The dynamics of peritoneal transport of solutes (in peritoneal equilibrium test, PET) and water (in mini-PET) was evaluated in a prospective interventional open-label study with historical control among 96 unselected consecutive patients admitted in three dialysis centers with unified program of peritoneal membrane monitoring and protection.

RESULTS: Compared to the matched standard arm, the increase in peritoneal solute transport was significantly slower (by 9.5%) in the observation group. Ultrafiltration in classical PET decreased more slowly (by 28%). At baseline ultrafiltration was satisfactory (the proportion of the patients with ultrafiltration less 400 ml was 7.6%); water transport by small pores did not decrease (−1.1 ± 5.9 ml/year), and the decrease in total ultrafiltration (by 32.1 ± 8.2 ml/year) was due to a decrease in free water transport (by 29.9 ± 7.6 ml/year). Negative dynamics of free water transport was associated with total glucose load and with monthly glucose load greater than 2.68 kg/month. More than one case of peritonitis was associated with a more rapid decline in free water transport. The comorbidity increased in 34 of 96 patients, with median first/last scores of 5 (4–6) and 6 (4–7) points; (Wilcoxon Z = −5.423; p < 0.001). When analyzed separately by peritoneal transport category, a significant worsening of the comorbidity index was observed only for high average and high transporters (Z = −2.754, p = 0.006 and Z = −3.357, p = 0.001, respectively).

CONCLUSIONS: The interaction between peritoneal transport, primarily free water transport, and cardiovascular disease is certainly two-way: deterioration of water balance due to loss of effective ultrafiltration leads to volume overload and progression of cardiovascular disease. On the other hand, cardiovascular disease contributes to peritoneal membrane damage. The most sensitive monitoring of interventions effectiveness in membrane protection and preventing cardiovascular disease progression is the separate measuring of water transport through small pores and ultrapores, which simultaneously reveals a feature of progressive peritoneal fibrosis, a potential precursor of encapsulating peritoneal sclerosis.

BACKGROUND: After recovery from COVID-19 patients may develop new risk factors that lead to changes in cardiopulmonary interactions, i.e. an increase in the afterload on the right ventricle due to increased pressure in the pulmonary artery and change in pulmonary vascular resistance. It can be assumed that the presence of such a spectrum of problems can influence the severity of dyspnea and the development of pathogenetic events (pulmonary hypertension, right ventricular failure, subendocardial ischemia), which in turn can determine the outcome.

AIM: To identify the characteristics of acute coronary syndrome after a COVID-19, taking into account angiographic data on coronary artery lesions and hemodynamic manifestations.

MATERIALS AND METHODS: A comparative analysis of the clinical and hemodynamic consequences of the COVID-19 and the development of acute coronary syndrome in 157 patients was carried out. The group 1 included 69 patients who had had COVID-19 (vaccinated — 24.6%) during the 6 months preceding acute coronary syndrome; group 2 — 88 patients without a history of COVID-19 (vaccinated — 42%). The 12-lead electrocardiogram has been used in the diagnosis of subendocardial ischemia in acute coronary syndrome. The ST segment displacement in lead aVR was analyzed.

RESULTS: After COVID-19, dispnoe occurred in 52% of the patients and in 14.8% without previous infection. Echocardiographic signs of right ventricular overload were present in 42% of the patients in group 1 and 10.2% in group 2. The mean pressure in the pulmonary artery was increased after COVID-19 in 58% of the patients in group 1 and in 10.2% of group 2 in the range from 20 to 24 mm Hg and in the range from 25 to 36 mm Hg in 29% of the patients in group 1 and 2.3% of the patients in group 2. The average value of left ventricular ejection fraction in the patients who had had COVID-19 was 55.9 ± 14%, which was less than in the patients in the control group (63.2 ± 5.5%; p < 0.001). ST segment elevation in lead aVr indicated high incidence of subendocardial ischemia. 40.6% in group 1, and 11.4% in group 2 (χ² = 17.9; p < 0.001); in group 1 vaccinated — 17.6%, and not vaccinated — 48.1% (χ² = 4.9; p = 0.027), in group 2 vaccinated — 8.1%, and not vaccinated — 13.7% (χ² = 0.7; p = 0.41). All the patients had drug-eluting stents implanted in the infarct-related artery. After stenting, no recurrence of pain or further increase in chest pain was observed.

CONCLUSIONS: After coronavirus infection COVID-19, 58% of patients have increased mean pressure in the pulmonary artery in the range from 20 to 24 mm Hg and in the range from 25 to 36 mm Hg in 29%. Atherothrombosis is the main mechanism of acute coronary syndrome after COVID-19 coronavirus infection. The main feature of acute coronary syndrome after a coronavirus infection COVID-19 is increased pressure in the pulmonary artery after a lung injury, which must be taken into account when planning surgical treatment tactics and management tactics in the postoperative period.

BACKGROUND: Osteoporosis is a metabolic skeletal disease characterized by decreased bone mass, impaired microarchitecture of bone tissue and, as a consequence, fractures with minimal trauma. The social significance of osteoporosis is determined by its consequences — fractures of the vertebral bodies and bones of the peripheral skeleton, leading to high medical costs and causing a high level of disability, including disability and mortality. Osteoporosis is most often combined with cardiovascular diseases caused by atherosclerosis, which are widespread and are the leading cause of disability and mortality. A small number of studies have been devoted to the study of the features of clinical manifestations of cardiovascular diseases in the combination of coronary heart disease and osteoporosis.

AIM: To identify the frequency and severity of comorbid diseases and their risk factors in postmenopausal osteoporosis.

MATERIALS AND METHODS: A retrospective and prospective cohort study was conducted from 2013 to 2023. 8250 women with postmenopausal osteoporosis were examined and the data from the medical records of these patients who applied to the Osteoporosis Center of the North-Western State Medical University named after I.I. Mechnikov of the Ministry of Health of the Russian Federation from 2013 to 2020 were analyzed. At the prospective stage, two comparison groups of 100 patients with and without postmenopausal osteoporosis were formed from 500 patients with comorbid diseases (coronary heart disease, hypertension, type 2 diabetes, stroke, transient ischemic attack). Bone mineral density was assessed based on the Hologic Discoveri Wi dual-energy X-ray absorptiometry at 2 points in the lumbar spine (L1–L4) and the femoral neck. Along with traditional laboratory examination methods, bone metabolism markers (total calcium, phosphorus, vitamin D, urine analysis for deoxypyridinoline, C-terminal telopeptide of type 1 collagen, osteocalcin, alkaline phosphatase, parathyroid hormone) were assessed dynamically. In all the patients, along with a general clinical examination, an assessment of risk factors for cardiovascular disease and osteoporosis was performed.

RESULTS: Body mass index was higher in the group of patients with osteoporosis — 28.4 (26.9–32.4) kg/m² (p < 0.001), versus 27.64 (25.8–30.0) kg/m² (p < 0.05). Bone mineral density in the group of patients with osteoporosis was statistically lower than in the group without osteoporosis. In the group of patients with osteoporosis, the risk of fractures was high and amounted to 37 (95% confidence interval 15.0–38.50) %, p < 0.001), versus in the control group 9.55 (95% confidence interval 7.67–15.0) % (p < 0.001) according to the FRAX questionnaire for the Russian Federation. In the group of patients with osteoporosis, the Charlson index values were 5.1 (95% confidence interval 4.7–5.6) points. As a result of the correlation analysis, a reliable positive relationship was revealed between low bone mineral density L1–L4 and hip with bone metabolism: alkaline phosphatase, C-terminal telopeptide of type 1 collagen, vitamin D, osteocalcin, urinary deoxypyridinoline. We found a negative relationship between bone mineral density and the Charlson index, absolute ten-year risk of hip fracture and the duration of early menopause, and the level of hypertension. To assess the dependence of QRISK3-2018 on osteoporosis risk factors in the group of patients with osteoporosis, multiple linear regression was performed. This model was characterized by a statistically significant correlation between the factors and the dependent variable of high tightness. The coefficient of determination was 0.608, indicating a 60.8% contribution of the factors taken into account in the model to the variance of QRISK3-2018.

CONCLUSIONS: In women with postmenopausal osteoporosis, comorbid pathology is more common, aggravating the course of the disease. Knowledge of the prevalence of concomitant pathology and joint risk factors will make it possible to simultaneously form groups at increased risk of development, which will ensure prevention of both diseases with the same non-medical means and drugs.

BACKGROUND: The significant prevalence of dyspepsia in patients without Нelicobacter pylori infection, difficulties in differential diagnosis necessitate the identification of the most common nosological variants, optimization of the diagnosis algorithm.

AIM: To study clinical, laboratory and instrumental characteristics of patients with dyspepsia syndrome unrelated to Нelicobacter pylori infection.

MATERIALS AND METHODS: A ¹³C-Urea Breath test was performed to 856 patients with uninvestigated dyspepsia. According to its results, 342 patients with Нelicobacter pylori infection were excluded from the study. The remaining patients (n = 514) with negative Нelicobacter pylori status underwent esophagogastroduodenoscopy and ultrasound examination of the abdominal organs. The patients with an identified organic pathology (n = 129) explaining dyspeptic complaints were excluded from the study. 208 out of the 385 patients without organic pathology agreed to undergo laboratory and instrumental examination in accordance with the study protocol. To assess dyspeptic complaints, 208 patients filled out a “Dyspepsia Questionnaire” developed by the authors. Demographic, anthropometric data, and complaints were recorded in all the study participants; experimental psychological testing was performed (Beck’s questionnaires, generalized anxiety disorder questionnaire-7, Short Form-36) and laboratory and instrumental examination (the level of pepsinogen I, pepsinogen II, immunoglobulin class G to Нelicobacter pylori and gastrin-17 in serum), esophagogastrogastroduodenoscopy with biopsy and pathomorphological assessment according to the Operative Link for Gastritis Assessment (OLGA) system, 24-hour esophageal impedance–pH monitoring, radiography of the esophagus and stomach.

RESULTS: The majority of the patients with dyspepsia syndrome were not infected at the time of Нelicobacter pylori complaints — 514 (60.1%) patients. An in-depth examination of 208 people with a negative helicobacter status and the absence of an organic pathology explaining the symptoms revealed the heterogeneity of the final diagnoses. The results of the study demonstrate positive correlations between the level of depression, anxiety and the AET (acid exposure time) index, the number of acid reflux. A decrease in the level of pepsinogen I, gastrin-17, and the ratio of pepsinogen I/II was revealed with an increase in the degree and stage of atrophy according to the results of an Operative Link for Gastritis Assessment biopsy.

CONCLUSIONS: The revealed variability of diagnoses and comorbidity in patients with similar complaints deepens the understanding of dyspepsia syndrome and explains the possible ineffectiveness of standard therapy regimens.

Cholelithiasis is a common problem in surgery. The pathological basis of the disease is a imbalance between cholesterol, bilirubin and bile acid metabolism. There are several risk factors for cholelithiasis, both modifiable and non-modifiable. Complications of this pathology most often require surgical intervention: either planned or emergency. One of such complications is choledocholithiasis. Most often, choledocholithiasis occurs as a result of migration of stones from the gallbladder, less often of stones form in the bile ducts. In the world and Russian literature, many works are devoted to the etiology, pathogenesis and the treatment of patients with choledocholithiasis. The diagnosis is confirmed using advanced imaging methods, such as magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. A widely used method of treatment is endoscopic retrograde cholangiopancreatography in combination with endoscopic papillosphincterotomy. However, in case of severe choledocholithiasis, including with an altered anatomical picture, standard methods do not always allow to achieve the desired result. This article describes a clinical case of successful treatment of a patient with choledocholithiasis that developed two years after gastropancreatoduodenal resection for adenocarcinoma of the major duodenal papilla.