Vol 78, No 11 (2003)


Communicablediseases: extending the traditional views

Рак S.G., Malov V.A., Gorobchenko A.N.
Terapevticheskii arkhiv. 2003;78(11):1-10
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Autoimmune manifestations in acute viralhepatitides

Volchkova Y.V., Allenov M.N., Umbetova К.Т., Ivanovo I.V., Pak S.G.


Aim. To study autoimmune reactions in patients with acute viral hepatitis A, B, and С in the dynamics of an infectious process. Materials and methods. 134 patients with acute viral hepatitides of various etiology were examined. Among them there were 36 patients with acute viral hepatitis A, 40 with B, and 58 with viral hepatitis С Antinuclear antibodies (ANA), antismooth muscle antibodies (SMA), and antimitochondrial antibodies (AMA) were determined by immunofluoresence assay using the test systems ATS COMVI-1, IMMCO diagnostics (USA). Serum rheumatoid factor was detected by the semiquantitative latex-agglutination test on a slide manufactured by the Human"firm (Germany). Cryoglobulins were identified by the qualitative visual method. Results. SMA, ANA were detected in the diagnostically significant titers (1:40-1:160) in patients with acute viral hepatitis A, B, and С A distinction of autoimmune manifestations was ascertained in viral hepatitis C. It has been demonstrated that in 71% of the patients cryoglobulins appear in the acute period of the disease and, in their presence, rheumatoid factor was found in 17.2% and 6.9% exhibited anti-LKM-1 and AMA. Conclusion. The presented data on the nature and time course of changes in autoimmune reactions in patients with acute viral hepatitis A, B, and С during an infectious process suggest that autoimmune disorders are characteristic of viral hepatic lesions just at the early stages of the disease irrespective of N 4. its etiology and play a prominent role in the pathogenesis of these nosological entities.
Terapevticheskii arkhiv. 2003;78(11):11-14
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A role of the body's antioxidativedefense system in the pathogenesis of acute viral hepatitides

Nagoev B.S., Ivanovo M.R.


Aim. To study the activity of antioxidative defense enzymes and the total plasma antioxidative activity in patients with viral hepatitis B, C, and mixed hepatitis В + С. Materials and methods. 77 patients with viral hepatitis B, 90 with viral hepatitis C, and 25 with mixed hepatitis В + С were followed up. The activity of superoxide dismutase and catalase of leukocytes, and the total plasma antioxidative activity were determined at the peak of the disease, allevia- tion of clinical symptoms, and before discharge from hospital. Results. At the peak of the disease, the patients with viral hepatitides showed suppressed activities of superoxide dismutase and catalase of leukocytes and suppressed total plasma antioxidative activity with increased these parameters by early convalescence, but without their normalization. There were the most pronounced changes in patients with severe mixed hepatitis В + С. Conclusion. The changes found in the body's antioxidative defense have been ascertained to depend on the etiology, stage, and severity of viral hepatitis.
Terapevticheskii arkhiv. 2003;78(11):15-16
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Clinical and laboratory features of severe forms ofacute viral hepatitis В

Kovelenov A.Y., Lobzin Y.V., Mikhaltsov A.N., Malkov A.N.


Aim. To establish the clinical and laboratory features of severe forms of acute viral hepatitis В (AVHB). Materials and methods. 141 patients (88 males and 53 females) with different forms of the disease were examined. Among them there were 30, 33, and 78 patients with mild, moderate, and severe AVHB, respectively. In 23 patients, the course of hepatitis was complicated by acute hepatic failure; 6 of them developed hepatic coma that resulted in death. All the patients underwent comprehensive clinical and biochemical studies; some of them did a special laboratory study including immunological monitoring, determination of some parameters of lipid peroxidation (LPO) and the antioxidative system (AOS) in the blood cells, examination of blood rheological properties (by the deformability and viscosity of erythrocytic biomembranes), and determination of the level of endogenous toxemia by the content of medium molecular-weight peptides in the plasma, red blood cells, and urine. Results. Pathogenetic features of severe forms of AVHB have been identified. These include: 1) a hyperimmune response to the invasion of mixed cellular and humoral virus, followed by hepatic macrophageal hyperactivation; 2) high activity of LPO with the development of AOS failure; 3) deterioration of erythrocytic rheological properties: the decreased deformability and increased viscosity of their biomembranes; 4) the maximal level of endogenous toxemia. Conclusion. New agents to enhance the efficiency of treatment of patients with severe AVHB should be sought in the following directions: immunomodulating, antioxidative, membrane-stabilizing, and disintoxicant ones.
Terapevticheskii arkhiv. 2003;78(11):17-22
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HG-viral infection in adults

Lisukova T.Y.


Aim. To characterize the clinical and laboratory manifestations in patients with HG viral infection frequently concurrent with chronic HCV infection and the potentialities of their treatment. Materials and methods. 109 patients with suspected chronic hepatic disease were examined. The markers of HGV, HCV, HBV, and TTVinfections were determined. The possible factors of infection, biochemical parameters, and the efficiency of antiviral therapy were assessed. Results. Hepatitis G virus RNK was detected in 32 cases, a combined variant of hepatitis G + С viruses RNA was found in 77 patients with chronic viral hepatitis (CVH). Among the presumed routes of contamination in the mixed variant of CVH, there were most common intravenous injection of narcotic drugs; in monoinfection (HGV), there were parenteral interventions in medical facilities and blood transfusion. Antiviral treatment of 13 patients with chronic HGV + HCV infection yielded a positive result in 5 patients after 3-month therapy. Conclusion. In patients with CVH, HG virus infection was more frequently observed in combination with CVHC, less frequently as monoinfection. In HG virus monoinfection, biochemical studies revealed the enhanced activity of transaminases and hyperbilirubinemia that was absent in the mixed variant of HGV + HCV. The financial capacities of patients should be taken into account while choosing therapy.
Terapevticheskii arkhiv. 2003;78(11):23-27
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Hematological masks of chronic viral hepatitis

Ryazantseva N.V., Beloborodova E.I., Novitsky V.V., Tokareva N.V., Tkachenko S.В., Beloborodova Y.V., Burkovskaya V.A., Knutareva Y.N., Antoshina M.A.


Aim. To reveal the structural features of the red blood cell membrane in patients with prolonged persistence of hepatitis В virus (HBV) and hepatitis С virus (HCV). Materials and methods. 61 patients with moderate and mild chronic viral hepatitis В and С were examined. A control group comprised 22 healthy donors. Fluorescence of the red blood cell membrane was performed, by using the following probes: pyrene, phenylnaphthylamine, l-anilinonaphthalene-8sulfonate. The activity of the ion-transporting enzyme Na+, K+-ATPase was determined. Results. Increases in the microviscosity of the lipid bilayer, periprotein lipid environment, as well as the structural modification of the surface layers of the membrane were found in patients with chronic hepatitis В and C. The activity of the membrane-bound enzyme Na+, K*-ATPase was statistically significantly decreased as compared with that in healthy donors. Conclusion. In HBV and HCV infection, the impairments of the red blood system are highly diversified: they involve bone marrow compartment of an erythron, as earlier shown, and its peripheral one. Molecular disorganization of the red blood cell membrane fails to present with obvious red blood cell dysfunctions. Despite the multifactorial property of their occurrence, impairments of the red blood system are mediated and corrected by many regulatory mechanisms at different organizational levels and may be compensated.
Terapevticheskii arkhiv. 2003;78(11):28-30
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Characterization of cellular immunity parameters in children with acute viral hepatitis A

Budarina N.A., Belaya О.F., Chulanov V.P., Paimanov N.V., Pak S.G.


Aim. To study the populational composition of lymphocytes and the specific features of production of cytokines in children with acute viral hepatitis A (A VHA). Materials and methods. 128patients aged 11 to 14 years who had AVHA, moderate AVHA being in 83.5% were examined. In 87.2% of the children, the disease was cyclic. The etiology of the disease was verified by symultaneously detecting anti-HAV IgM (enzyme immunoassay) and by the presence of HA V RNA (polymerase chain reaction) in the blood. Peripheral lymphocytes (CD) were phenotypes in the indirect immunofluorescence test using monoclonal antibodies; cytokines were determined by the enzyme immunoassay; serum p2-microglobulin was done by radioimmunoassay. Results. The children with AVHA were found to have elevated levels of tumor necrosis p-factor, interleukin-ip (IL-ip), and IL-4 in the icteric period, as well as a decrease in their levels at convalescence. IL-6 was detected in individual patients only in the first 3 days of the icteric period. The peak of A VHA was characterized by relative lymphocytosis, by decreases in the counts of T helper/inductor cells and natural killer cells, by increases in the count of CD25 cells, convalescence, by preserved lymphocytosis, by the increased levels of T lymphocytes that carry the markers CD3, CD4, CD8, CD16, CD25, and CD95, and by higher toxicity of p2-microglobulin.
Terapevticheskii arkhiv. 2003;78(11):31-35
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Development of approaches to enhancing adherence of patients withhuman immunodeficiency virus infection to antiretrovirustherapy

Belyaeva V.V., Kravchenko A.V., Pokrovsky V.V.


Aim. To study approaches to enhancing adherence of HIV-infected patients receiving antiretrovirus therapy. Materials and methods. 25patients (including 3 females) aged 18 to 45 years receiving VAART (fortovasa + norvir + videx, and viramun) were examined. While treating the patients, group classes were conducted to enhance their adherence to the therapy, followed by individual consultations in order to consolidate the obtained effect. The adherence to the therapy was rated by the patients' self-reports. Results. There was an increase in the activity and openness of those who attended group classes and positive changes in their self-assessment. Approaches to enhancing adherence and a model of school for HIV-infected individuals were developed. Conclusion. It has been shown that a combination of patients' awareness of different HlV-infectionassociated problems with consulting allows treatment motivation to be increased.
Terapevticheskii arkhiv. 2003;78(11):36-38
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Nuclear magnetic resonance serum relaxometry in patients withdifferent forms of erysipelas in the dynamics of the disease

Erovichenkov A.A., Kozinets G.I., Popova O.V., Anokhina G.I., Kolaeva N.V., Shabalina O.Y., Pak S.G.


Aim. To study the time of nuclear magnetic resonance (NMR) of spin-lattice serum relaxation (Tl) in the dynamics of an infectious process in patients with different forms of erysipelas. Materials and methods. 37 patients with different clinical forms of erysipelas were examined in the acute period of the disease and in the early period of convalescence. Results. A statistically significant increase in Tl NMR was ascertained in patients with bullous hemorrhagic erysipelas as compared with those with erythematous form. Conclusion. Pronounced changes in the functional status of serum in patients with hemorrhagic forms of erysipelas are of great importance in the development of the local hemorrhagic syndrome.
Terapevticheskii arkhiv. 2003;78(11):39-41
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Potentialities of use of affinity interaction of biologically active substances in practice of public health system

Pokrovsky V.I., Maleev V.V., Zborovsky А.В., Efremenko V.I., Gontar I.P., Tyumentseva I.S., Afanasyev Y.N.


Aim. To determine the potentialities of use of affinity interaction of immobilized biologically active substances (bacterial cells or their fragments, toxins, antigens of various chemical nature, immunoglobulins, enzymes, gangliosides, etc.) for medical practice. Materials and methods. Emulsion polymerization of acrylamide monomers in the gaseous nitrogen current was used as a basic method for preparation of solid-phase magnetic immunosorbents (MIC). A procedure for preparation of siliceous MIC was also applied. The prepared MICs were used a solid phase in enzyme immunoassay and immunofluorescence assay and the recorded data were compared with those of stidied conventionally used in practical medicine. Results. The use of MIC made it possible to detect pathogens of particularly dangerous infections in large volumes of the samples contaminated with another microflora. With the proposed MIC, one can stand a good chance of surveying large contingents of the population, of obtaining the quantitative results in shorter periods to establish a diagnosis. With this, the sensitivity and specificity of immunoassays substantially increase. Whether MIC may be used as selective hemosorbents to remove specific antibodies from the blood of patients with rheumatic diseases for therapeutic purposes was studied. Conclusion. The findings are indicative of wide potentialities of use of affinity interaction of biologically active substances immobilized on inert carriers with the inserted magnetic material in the laboratory diagnosis of diseases of both infectious and autoimmune nature, which may be widely used in the inand outpatient settings.
Terapevticheskii arkhiv. 2003;78(11):42-45
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WHOMONICA program-based study of awareness of their healthand attitude to the latter in males and females aged 25-64years from Novosibirsk

Gafarov V.V., Pak V.A., Gagulin I.V., Gafarov A.V.


Aim. To assess the attitude of the Novosibirsk population towards its health, its readiness to participate in preventive measures and to implement guidelines for changing lifestyle. Materials and methods. A random representative sample of males and females (a total of 2400 individuals) aged 24 to 64 years from one of the Novosibirsk districts was examined within the framework of the second screening of the MONICA program studying the trends and monitoring cardiovascular diseases and the "MOPSY-MONICA-psychosocial" subprogram. The examination included the conventional procedures described in the MONICA project. Sleep disorders, health self-assessment, and attitude to smoking were studied by means of the questionnaire "Awareness and Attitude towards Health" adapted to the studied population. Results. More than 60% of the males and 85% of the females reported that they were not quite healthy or ill, only 7% of the individuals had their health examined although almost 100% noted that they were most likely to fall ill with a serious disease within 5-10 years. The males were more optimistic in their assessments than were the females. With age, the frequency of assessments, such as "not quite healthy" and "ill", concern about their health, and participation in prophylactic examinations increased. 45% of the respondents reported about the high level of stress in their working place. The opportunity of the examinees to have a rest at home was extremely little. Family stress was significant for both sexes. The females showed a more negative attitude towards smoking than did the males (55% of the males and 5% of the females were smokers). The males more frequently considered that they did not need to alter dietary habits and to do exercises than did the females. A total of 2.4% of the males and 2.5% of the females changed their dietary habits for their health. Only 50% of the males and 31% of the females slept well or very well, this parameter decreased with age. Conclusion. Despite a positive motivation in the context of prophylaxis, there are negative trends in both social and behavioral characteristics of the population. The most intensive measures for altering the behavioral characteristics of the population and for softening the impact of stress on the population are required at the governmental level.
Terapevticheskii arkhiv. 2003;78(11):46-52
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Comparative evaluation of cardiac hemodynamics and endothelium-dependent reactive hyperemia in arterial hypertension in those living in high-altitudeand plain areas

Doloman L.В., Beslaneev I.A., Batyrbekova L.M., Kurdanov K.A., Sagach V.F.


Aim. To reveal the specific features of cardiac hemodynamics and endothelial function in high-altitude native dwellers with arterial hypertension (AH). Materials and methods. 90 native dwellers from high-altitude and plain areas, who had Stages I and II AH, were examined. To assess cardiac contractility, central and peripheral hemodynamics, the authors used electrocardiography, echocardiography, tetrapolar impedance rheoplethysmography. The functional status of the endothelium was evaluated by the reproduction of endothelium-dependent reactive hypermia in the antebrachial vessels. Results. The patients with Stages I and II AH who live in high-altitude area have been found to have less pronounced peripheral vasocontriction due to the less suppression of pump and contractile functions of the heart. Total peripheral resistance in high-altitude dwellers with Stage II AH is practically similar to that in plain inhabitants with Stage I AH. The extended vasodilator reserve in high-altitude inhabitants with AH is also shown by the data obtained in the reproduction of reactive hyperemia in the antebrachial vessels. A less marked decrease in this vascular reaction in patients with AH who live in high-altitude areas may be due to additional production and/or release of nitric oxide in order to increase the vasodilator reserve in moderate hypoxia. Conclusion. The course of AH in high-altitude dwellers is marked by less suppression of cardiac pump and contractile functions and less peripheral vasoconstriction. This may be accounted for by compensatory activation of endothelial vasodilator mechanisms aimed at preserving adequate tissue perfusion and at optimally providing the body with oxygen in moderate hypoxia.
Terapevticheskii arkhiv. 2003;78(11):52-55
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Impact of long-term antihypertensive therapy on the vasoregulating function of the brachial artery in patients with arterialhypertension associated with type 2 diabetes mellitus

Karpov R.S., Koshelskaya O.A., Falkovskaya A.Y., Ocheredko N.A., Atroshenkov A.V., Makarova Y.V.


Aim. To evaluate the impact of 6-month-to-one-year antihypertensive therapy on the vasoregulating function of the brachial artery and predictors of its efficiency in 75 patients with stages I-II arterial hypertension associated with type 2 diabetes mellitus. Materials and methods. An open randomized study of parallel groups of patients receiving angiotensin-converting enzyme (ACE) inhibitors, calcium blockers (verapamil) and their combination and in those who did not take antihypertensive therapy examined endothelium-dependent vasodilation (EDVD) according to the data of ultrasound scanning and Doppler study of brachial arterial blood flow as compared with changes in metabolism and 24-hour blood pressure profile. Results. A positive effect of verapamil on the baseline impaired EDVD is realized only in the presence of an adequate compensation of glycemia, at the normal blood level of Cortisol, occurs in parallel with increased nonendothelium-dependent vasoreactivity, and associates with the magnitude of an antihypertensive effect. ACE inhibitors improve decreased EDVD irrespective of the degree of glycemic control, the blood level of Cortisol without a clear correlation with the altered non-endothelium-dependent vasoreactivity and with the degree of an antihypertensive effect. Combined therapy with these agents causes decreases in baseline insulinemia and the athoregenicity index and it can improve impaired vasoreactivity even in case of incomplete antihypernsive therapeutic effect. Conclusion. The differences found in the effect of ACE inhibitors and verapamil on baseline decreased EDVD provide evidence for differential use of these drugs to correct impaired vasoreactivity in patients with AH associated with DM. The combined antihypertensive therapy fails to produce a positive impact if significant hypercholesterolemia (total blood cholesterol being more than 6.5 mmol/l) and stenosing peripheral atherosclerosis are present.
Terapevticheskii arkhiv. 2003;78(11):56-60
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Content of the antigenic determinants CD16, CD 25,CD95, and HLA-DR in the induced sputum of patientswith bronchial asthma and chronic obstructive bronchitis

Nevzorova V.A., Konovalova Y.N., Pazych S.A., Kostyushko A.V.


Aim. To examine the content of CD16, CD 25, CD95, and HLA-DR antigenic determinants in induced sputum (IS) of patients with bronchial asthma (BA) and chronic obstructive bronchitis (COB). Materials and methods. The study enrolled 36 patients with BA and 15 with COB whose age was 21 to 58 years. The cellular precipitate of IS served as a material for the study. The studied receptors were determined by immunofluorescence using the "Clonospectrum " monoclonal antibodies. Results. There was an increase in the content of CD16, CD25, HLA-DR, CD95 whose expression was decreased when glucocorticosteroids were used. At remission of asthma, the level of these receptors approximated that in the control group. On an exacerbation of COB, the content of these markers was significantly less than that in the controls and the use of antibacterial agents and methylxanthines led to its rise. At remission of COB, CD 16 and CD25 cells were not recorded. Conclusion. The levels of membrane markers in IM of patients with BA and COB depend on the period of the disease and used therapy.
Terapevticheskii arkhiv. 2003;78(11):61-63
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Evaluation of the efficacy of inhaled glucocorticosteroids in mildbronchial asthma

Terpigorev S.A., Ilchenko V.A., Koltsun S.S., Goryainov A.D., Stotskaya T.V., Averina Т.К., Paleev N.R.


Aim. To develop a procedure for evaluating the efficacy of antiiflammatory agents in mild persistent bronchial asthma. Materials and methods. 76 patients with mild bronchial asthma were given long acting theophylline. If a complete clinical and functional effect was absent, the inhaled glucocorticosteroid budesonide was added to the therapy. Before and after therapy, the forced expiratory volume per second and forced vital capacity (FVC) were measured many times within 24 hours, by using two procedures: 1) that involving morning and diurnal tests using short acting B2-agonists and 2) that without a bronchodilator. The time of onset of the plateau of values of different functional indices obtained during monitoring and their dispersion in the stable state were automatically calculated. The reliability of indices for evaluating the efficiency of antiinflammatory therapy was compared. Results. There were great differences in the patients' response to therapy: a complete clinical and functional effect of therapy with long acting theophylline alone (n = 9) and in combination with budesonide (n = 56). Moreover, therapy-resistant patients (n = 11) were identified. When a complete therapeutic effect was achieved, the clinical symptoms of the disease disappeared before the onset of the plateau of values of the most reliable functional indices. A comparative analysis of the indices has indicated that the ratio of the morning value of FVC measured just after awakening to its best personal value throughout the study was most convenient for the patients and reliable. Conclusion. The authors propose to use the index "ratio of the morning value of FVC measured just after awakening to its best personal value the percentage", by calculating the dispersion of this index, which characterizes the steady state of the expiratory respiratory system in order to evaluate the efficiency of antiinflammatory therapy for bronchial asthma and to solve other problems that require functional monitoring.
Terapevticheskii arkhiv. 2003;78(11):64-67
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Hypogammaglobulinemia sprue

Parfenov A.I., Krums L.M., Gudkova R.В., Sivash E.S., Chikunova B.Z.
Terapevticheskii arkhiv. 2003;78(11):68-70
pages 68-70 views

Results of an open multicenter study of theefficiency of one-week antihelicobacter therapy using omeprazole, clarithromycin, and amoxycillin in patients withduodenal peptic ulcer

Isakov V.A., Maev I.V., Simanenkov V.I., Kononov A.V., Abdulkhakov R.A., Zakharova N.V., Livzan M.A., Predvechnaya I.K.


Aim. To study the efficiency of one-week antihelicobacter therapy using omeprazole, clarithromycin, and amoxycillin in patients with duodenal peptic ulcer during its recurrence. Materials and methods. 105 patients with recurrent peptic ulcer and a not less than 0.5-cm ulcer in the duodenal bulb was given triple therapy: omeprazole, 20 mg twice daily, amoxycillin, 1000 mg twice sidaily, and clarithromycin, 500 mg twice daily for 7 days. Then the patients were allowed to take antacids if they were required to abolish the symptoms of recurrent peptic ulcer. H. pylori was detected in the mucosal biopsy specimens taken from the anthral part and body of the stomach at gastroduodenoscopy, by using the rapid urease test and histology. Gastroduodenoscopy was performed before and 4-6 weeks after the triple therapy. Results. The major symptoms of recurrent peptic ulcer were eliminated in 90% of the patients by the end of a course of therapy, i.e. on its day 7. By the control time, the rate of ulcer cicatrization was 99.05% (104/105). The coincidence of results of the two tests has indicated that H. pylori eradication was 81.9% (86/105) 4-6 weeks after termination of treatment. Adverse reactions during therapy were observed in 20% of the patients; however, treatment had to be discontinued only in 2.9% of the patients. Conclusion. One-week triple therapy using omeprazole, clarithromycin, and amoxycillin is highly effective in treating duodenal peptic ulcer during its recurrence.
Terapevticheskii arkhiv. 2003;78(11):71-72
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Hormonal and immunological aspects of renal lesions in patients with chronic alcoholism

Tarasova N.S., Beloborodova E.I.


Aim. To analyze a relationship of the level of sex hormones to the tension of immunological processes in definite renal diseases in patients with chronic alcoholism. Materials and methods. 43 patients with chronic alcoholism who also suffered from chronic renal disease were examined. The levels of plasma testosterone and estradiol were determined by radioimmunoassay using labeled 3H-hormones, as described by V. S. Goncharov and G V. Katsiya. The immunity was assessed by determining the activity of secreted interleukin-1 in the cultured peripheral monocytes of the patients and in the cultured renal glomerular mesangial cells by radioimmunoassay according to the procedure of S. Mizel and О. V. Gabrilevskaya. The obtained renal biopsy specimens were examined by electron microscopy immunoassay, as described by A. A. Ivanov. The activity of lysosomal enzymes was studied. Results. Activation of lysosomal enzymes and increased synthesis of interleukin-1 by monocytes and mesangial celts were observed in patients with chronic alcoholism and renal diseases with testosterone deficiency and excess estradiol in the plasma. There was a correlation of the level of estradiol with that of interleukin-1 and with the activity ofcathepsin D. Conclusion. With hypofunction of androgens, estrogens stipulate the tension of immune reactions, which finally leads to renal lesion in patients with chronic alcoholism.
Terapevticheskii arkhiv. 2003;78(11):73-76
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Intestinal candidiasis: Diagnosis and treatment

Shevyakov М.A.
Terapevticheskii arkhiv. 2003;78(11):77-78
pages 77-78 views

Herpesvirus es-ophagitis

Yushchuk N.D., Maev I.V., Busarova G.A.
Terapevticheskii arkhiv. 2003;78(11):79-83
pages 79-83 views

Thepathogenesis of sepsis: Current aspects

Grachev S.V., Pak S.G., Malov V.A., Gorodnova Y.A.
Terapevticheskii arkhiv. 2003;78(11):84-88
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Andrei Ivanovich Vorobyev (on the occasion of his 75th birth-day)

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Terapevticheskii arkhiv. 2003;78(11):94-95
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