卷 13, 编号 3 (2021)

Diarrhea is the most common adverse reaction of anticancer drugs, as well as radiation therapy of the pelvic organs or abdominal cavity: the incidence of diarrhea of different seveity reaches 80% during chemotherapy and / or radiation therapy; one third of these patients develop severe diarrhea (3^rd or 4^th degree). Most often, drug-induced diarrhea occurs during chemotherapy, using 5-fluorouracil or irinotecan, taking new anticancer drugs from the classes of checkpoint inhibitors, monoclonal antibodies, tyrosine kinase inhibitors. The most common mechanisms underlying the development of drug-induced diarrhea are damage to the intestinal mucosa, impaired absorption of proteins, carbohydrates, fats, inflammation, a perverse immune response, microflora imbalance, and others.

Algorithms for the management of patients with severe diarrhea include suspension (grade 1-2, 3) or complete cessation (grade 4, grade 3) of the use of an antineoplastic agent – an inducer, prescribing drugs that reduce intestinal motility (loperamide) while excluding the infectious nature of diarrhea, intravenous methylprednisolone (for example, diarrhea caused by monoclinal antibodies in the absence of suspicion of potential bowel perforation). In cases where drug-induced diarrhea lasts more than 48 hours, or a patient reports symptoms of dehydration, or a fever occurs, urgent hospitalization is necessary.

The objective of this review is to analyze scientific literature data on the prevalence, pathophysiological mechanisms and risk factors for the development of diarrhea associated with the intake of anticancer drugs, as well as its prevention and treatment.

About 5% of the population suffer from chronic diarrhea. Intestinal infections are the most common cause of diarrheal syndrome. However, if they are excluded, it is necessary to check for other possible reasons: vascular, oncological, rheumatic, drug-induced, radiation diseases and other gastroenterological pathology except from inflammatory bowel diseases.

When predicting and detrcting new predictors of unfavorable outcomes and progression of inflammatory bowel diseases, special attention has been recently paid to serological markers and genetic research, which have not yet entered clinical practice due to their high cost.

Inflammatory bowel diseases is a diagnosis of exclusion, which is made after a comprehensive assessment of clinical, laboratory, endoscopic, and morphological data. In case of the development of complications, it needs to investigate new available prognostic markers of inflammatory bowel diseases course.

论证。目前，无症状高尿酸血症对心血管疾病、代谢紊乱和慢性肾脏疾病的发展和进展的负面影响是众所周知的。但文献对高尿酸血症与类风湿关节炎合并病程的特点还不够全面。

本研究的目的是研究高尿酸血症与类风湿关节炎的临床实验室、免疫学、放射学和功能特征之间的关系。

材料与方法。2000年1月至2020年4月期间，对524名类风湿性关节炎患者的数据进行了分析，其中262名患者（主要组）被发现有高尿酸血症—血清尿酸水平超过360 mmol/L。其余262名患者为对比组。主要组被分为两个亚组，即低（<500 mmol/L）和高（≥500 mmol/L）高尿酸血症患者。该研究包括440名女性和84名男性，平均年龄为60±13.6岁。统计分析包括患者人口统计学（性别、年龄）、诊断、是否有高尿酸血症和持续时间、随访时间、类风湿性关节炎的活动和治疗，以及其实验室、免疫学、放射学和功能特点等信息。

结果。在高尿酸血症亚组的患者中，男性多于低尿酸血症亚组和对比组。每三分之一的患者在关节有显著的结构改变（III和IV影像学分期）。在98%的患者中，发现中度和明显的功能限制（功能II和III级）。 主要组的平均年龄最高。与没有高尿酸血症的患者相比，高尿酸血症患者看医生的次数更多，对类风湿关节炎的随访时间更长，放射学进展更少，关节疼痛和肿胀更严重，服用甲氨蝶呤的次数和剂量更少，服用柳氮磺胺吡啶的次数更多。

结论。高尿酸血症对类风湿关节炎的病程有负面影响。它与直接（更疼痛和肿胀的关节）和间接 （更长的观察时间和看医生的次数）症状有关。高尿酸血症与公认的活动标志物（红细胞沉降率、 C-反应蛋白水平、DAS28指数）和类风湿性关节炎的免疫学特征（类风湿因子，环瓜氨酸肽抗体阳性） 缺乏相关性，以及与它的放射学进展、功能性关节衰竭和骨密度下降速度之间的模糊关系，都是由免疫抑制疗法引起的。

BACKGROUND: A new format for assessing impaired functions, disabilities and health in accordance with the international classification (ICF), which is necessary at all stages of rehabilitation, is considered of great importance in the practice of an interdisciplinary rehabilitation team. However, in practice, the use of the ICF is very limited due to a number of organizational reasons.

AIM: To raise awareness among specialists of different fields involved in the rehabilitation of a disabled person, about the main provisions of the ICF; discuss the gradation of rehabilitation potential developed by the authors in cardiac patients.

MATERIALS AND METHODS: An analysis of referrals to the medical and social expertise bureau (form 088 / U) of patients with cardiovascular diseases has been carried out with the allocation of groups of low and high rehabilitation potential.

RESULTS: An analysis of the main provisions of the ICF regulating the section of cardiovascular diseases is presented. This classification is the “gold standard” for assessing the quality of life and medical services provided, substantiating the need, volume and composition of individual rehabilitation measures for a disabled person. The ways of using the principles laid down by the ICF in clinical practice for evaluating the results of complex rehabilitation of patients with cardiac pathology are discussed. The main provisions of the ICF, influencing the quality of rehabilitation measures in patients with cardiological profile, are highlighted. A list of diseases / conditions has been developed and proposed for use, which involves various levels of rehabilitation.

CONCLUSIONS: The authors have developed and proposed for discussion the gradation of the rehabilitation potential of patients with cardiovascular diseases, as well as discussed the general provisions of the international classification of functioning, simplifying and facilitating the use of ICF in practical work, taking into account the standards of examination, treatment and rehabilitation for cardiac patients in accordance with the standards of examination, treatment and rehabilitation of cardiac patients approved in the Russian Federation.

论证。肠易激综合征是最常见的胃肠道疾病之一。其症状显著降低了病人的生活质量。由于目前对这种综合征的治疗缺乏疗效，有必要寻找药理作用针对其形成的发病机制的新药。目前，人们越来越关注上皮通透性增加综合征对肠易激综合征的影响，将通用的细胞保护剂瑞巴匹特纳入患者的综合治疗中是很有希望的。

这项研究的目的是评估瑞巴匹特对肠易激综合征病程的影响。

材料与方法。本文介绍了SOCRIC研究的中期结果，该研究对40名肠易激综合征患者进行了检查，将其分为性别、年龄和疾病类型可比较的两组。 主要组（n=21）患者在标准抗痉挛治疗的基础上给予瑞巴匹特治疗，对照组（n=19）患者给予三钾二枸橼酸铋。采用GSRS、7×7问卷、IBS-QOL和视觉模拟量表对患者治疗前后的胃肠病主诉进行评估。

结果。两种药物都改善了病人的状况，但瑞巴匹特的积极作用更明显，这表现在主组病人的腹痛和便秘引起的症状的频率和严重程度都明显降低。

结论。研究表明，瑞巴匹特的保护活性不仅能减轻症状，而且对肠易激综合征的病程也有积极影响。

INTRODUCTION: Immune checkpoint inhibitors (ICIs) have significantly improved the prognosis and clinical outcomes for patients with malignancies in many types of cancer. Nivolumab is a human monoclonal antibody that blocks the interaction between PD-1 and PD-L1/2, thereby preventing inhibition of T-cells, which contributes to the antitumor response. The use of ICT can lead to autoimmune aggression and the development of adverse events. Most of these are eliminated on their own after ICT therapy and steroid treatment have been discontinued.

CLINICAL CASE DESCRIPTION: A 73-year-old patient with recurrent large B-cell lymphoma, on the background of R-CHOP, R-CHOP-mini, R-GDOx therapy incomplete clinical effect and frequent relapses have been registered. On immunohistochemistry, PD-L1 was positive in 90 % of the tumor cells. A decision has been made to administer the checkpoint inhibitor (PD-1) nivolumab, which developed a necrotizing vasculitis after three injections.

CONCLUSION: On temporary withdrawal of the drug and administration of prednisolone at a dose of 1 mg/kg/day, the skin has recovered completely. When the PD-1 inhibitor was reapplied, there was no recurrence of autoimmune aggression. The treatment has been continued in the full way.