Vol 82, No 8 (2010)


Community-acquired pneumonia in adults: Approaches to antibacterial therapy in the context of current clinical guidelines

Sinopalnikov A.I.


Conciliatory guidelines for management of patients with either disease/abnormality have recently become an integral part of medical practice. The popularity of the guidelines is likely to owe to the fact that they are a more or less successful synthesis of abundant information within one document, by giving a physician detailed many-year and many-decade clinical and scientific experience. Since their publication, they become a peculiar standard of medical care delivery. The main benefit of such guidelines should be seen in the diagnosis and treatment standardization (without a physician's losing his/her reasonable autonomy in each individual case) that makes it possible to optimize a diagnostic process, to apply more effective therapeutic approaches, and to use less health care resources. By taking into account the drastically changing epidemiology of resistance of the causative agents of respiratory tract infection, the emergence of new antibiotics, and the rethinking of conventional diagnostic and therapeutic approaches, there is an apparent need for periodic revision and modification of such guidelines. In this regard, of particular interest are the conciliatory guidelines of the Russian Respiratory Society and Interregional Association of Clinical Microbiology and Antimicrobial Chemotherapy, which were published in 2010.
Terapevticheskii arkhiv. 2010;82(8):5-10
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Osteoprotegerin and bone mineral density in patients with chronic obstructive pulmonary disease

Kochetkova E.A., Nevzorova V.A., Maistrovskaya Y.V., Massard G.


Aim: to study a relationship between the serum level of osteoprotegerin (OPG), the markers of bone metabolism, tumor necrosis factor-α (TNF-α), and bone mineral density (BMD) in patients with chronic obstructive pulmonary disease (COPD). Subjects and methods. Fifty-five patients aged 44 to 58 years who had COPD were examined. BMD in the lumbar spine (LII-LIV) and left femoral neck (FN) was estimated by dual-energy X-ray absorptiometry (DXA) on Lunar Prodigy Densitometer (USA). The serum levels of OPG, BCrossLaps (BCL), and TNF-α were measured. A control group comprised 25 healthy non-smoking gender- and age-matched volunteers. Results. Osteopenic syndrome (T-test < -1SD) was recorded in 43 (78%) of the 55 examined patients with COPD. In 29 (52%) of them, T-test was lower in two zones towards osteoporosis in 14 (25%) towards osteopenia. In patients with COPD, TNF-α concentrations were significantly higher than that in the control group. At the same time, TNF-α levels correlated positively with the bone resorption marker BCL (r = 0.52; p = 0.042) and negatively with OPG (r = 0.56; p = 0.003). A direct correlation was established between serum OPG concentrations and BMD in both LII-LIV and FN (r = 0.56; p < 0.01 and r = 0.47; p < 0.05, respectively) Conclusion. The patients with COPD were found to have lower BMD, elevated TNF-α concentrations, an increased bone resorption marker, and lower serum OPG levels. The associations between the levels of OPG, TNF-α, and BMD suggest that these markers are implicated in the pathogenesis of osteopenic syndrome in COPD.
Terapevticheskii arkhiv. 2010;82(8):10-14
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Clopidogrel resistance in patients with acute coronary syndrome

Frolova N.S., Shakhnovich R.M., Sirotkina O.V., Dobrovolsky A.B., Ruda M.Y.


Aim: to reveal the frequency of clopidogrel resistance in patients with acute coronary syndrome (ACS) and its impact on prognosis in these patients. Subjects and methods. Seventy-five clopidogrel-treated patients with ACS were followed up. Optical aggregometry was conducted using ADP 20 μmol. The resistance criteria were baseline platelet aggregation, platelet aggregation on day 7, % < 10%. Inflammatory markers (IL-6, IL-10, and C-reactive protein) were determined. Genetic polymorphisms (the IIIa subunit gene - Leu33Pro, the receptor P2Y12 C18T and G36T gene, and the CYP3*A4(A-293G) gene) were studied. Results. According to the accepted resistance criteria, 54 (72%) patients were sensitive to clopidogrel and 21 (28%) were resistant to the agent. The resistance was revealed in 7 (23%) of the patients with ECG ST-segment elevation and in 14 (31%) of those with ST-segment elevation. Before admission to the clinic, the unresponsive patients had significantly more frequently received the loading clopidogrel dose of 300 mg while that latter was 600 mg in the responsive patients. As compared with the responsive patients, the unresponsive ones showed a significantly lower baseline antibody level that was increased on day 7. The clopidogrel resistance determined by this criterion had no impact on prognosis. On dividing the patients by aggregation quartile values, poor manifestations insignificantly more frequently occurred in the third and fourth quartiles. No clear correlation was found between the occurrence of clopidogrel resistance and the activation of an inflammatory process. The monozygous variant of the receptor P2Y12 CT18T gene was insignificantly more frequently encountered in the unresponsive patients. Conclusion. The laboratory phenomenon of clopidogrel resistance exists. Large multicenter studies of this issue are needed to identify simple and least expensive resistance methods and clear diagnostic criteria that enable the findings to be compared.
Terapevticheskii arkhiv. 2010;82(8):14-20
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Implantation of the paclitaxel-eluting stent Apollo in patients with stable angina pectoris: Long-term angiographic and clinical results

Batyraliev T.A., Fetser D.V., Samko A.N., Sidorenko B.A.


Aim: to assess the long-term angiographic and clinical results of percutaneous coronary interventions (PCI) with implantation of the drug-eluting stent (DES) Apollo in patients with stable angina pectoris. Subjects and methods. The study enrolled 48 patients with stable angina who had been implanted with 59 stents. A follow-up of the patients lasted 12 months. Results. The intervention was successful in 100% patients. Following 12 months, 81.3% of the patients underwent angiography that demonstrated that the vascular diameter decreased by 0.32±0.45 mm and the rate of restenosis was reduced by only 5.3%. The frequency of evident cardiac complications over 12 months was as high as 11.6%. Conclusion. The DES Apollo provides a way of safely performing PCI, by achieving a high of angiographic success rate. The application of this stent yields long-term good angiographic and clinical results in patients with stable angina pectoris.
Terapevticheskii arkhiv. 2010;82(8):20-23
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Determination of the levels of brain natriuretic peptide and its N-terminal fragment for the evaluation of the efficiency of renal replacement therapy modalities in patients with decompensated chronic heart failure

Tabakyan E.A., Zaruba A.Y., Rogoza A.N., Ataullakhanova D.M., Kukharchuk V.V.


Aim: to compare the capabilities of identifying different types of brain natriuretic peptide (BNP) for the evaluation of renal replacement therapy modalities in patients with decompensated chronic heart failure (CHF). Subjects and methods. Patients (31 men and 9 women) aged 30 to 82 years with functional class II-IV CHF in its decompensation phase were examined. The patients were divided into 2 groups. A study group received medical therapy for CHF, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists, verospirone, β-adrenoblockers, digoxin, loop diuretics (furosemide, diuver, in the doses not exceeding those taken before admission) in combination with renal replacement therapy: slow continuous ultrafiltration (SCUF) or continuous venovenous hemofiltration (CVVHF). A control group had only medical therapy for CHF (intravenous furosemide in the doses doubling those used before admission, i.e. l 80 mg/day required for an adequate response to the drug - daily urine volume > 1 liter). The patients from the study and control groups received furosemide m 40 mg/day or torsemide m 20 mg/day after a course of SCUF or CVVHF sessions or intravenous furosemide. There were 4 examination stages [control study points (CSP)]: 1) before study; 2) after CHF compensation achievement (a day before hospital discharge); 3) following 90 days; 4) following 180 days. The plasma concentration of active BNP was measured by enzyme immunoassay; that of the N-terminal fragment of BNP (NT-proBNP) was estimated on an analyzer. Results. There were direct correlations between the content of BNP and that of NT-proBNP) in all CSPs in the patients from both groups. The study group showed a significantly greater weight loss, which was accompanied by a more pronounced reduction in systolic pulmonary artery pressure, pulmonary venous hypertension, hydrothorax elimination, decreased liver size, lower plasma aldosterone concentration, decreased heart size, and higher left ventricular ejection fraction (LVEF). The study group displayed a steady-state reduction in the plasma concentrations of both BNP and NT-proBNP, significant inverse correlations between the lower BNP level and the higher LVEF throughout the follow-up. Conclusion. Extracorporeal dehydration techniques are more effective that intravenous diuretics. The direct correlations between the content of BNP and that of NT-proBNP and between the change in their concentrations during treatment assume the capacity and objectification of diagnosing CHF and its degree, by determining only one of the types of BNP.
Terapevticheskii arkhiv. 2010;82(8):24-29
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Risk factors for venous thromboembolic events and their association with D-dimer level

Vorobyeva N.M., Panchenko E.P., Dobrovolsky A.B., Titayeva E.V., Fedotkina Y.A., Kiriyenko A.I.


Aim: to study the prevalence of various risk factors (RF) for venous thromboembolic events (VTEE) and their association with D-dimer levels. Subjects and methods. The clinical, demographic, anthropometric, anamnestic, and laboratory data were analyzed in 106 patients (73 men and 33 women) aged 18 to 78 years admitted to hospital with the first or recurrent episode of VTEE. Results. RF and VTEE-associated diseases were identified in all patients. Over 90% of the patients had more 2 RFs. The most common RFs were the age above 40 years (85%) and overweight (82%), including obesity (42%). There was a preponderance of cardiovascular diseases in the pattern of VTEE-associated diseases. The direct causes (precipitating factors) of thrombosis were revealed in 57% of cases; the thrombotic episode was classified as idiopathic in 43%. Elevated D-dimer levels were found in 74% of the patients. Higher D-dimer content was seen in women, non-smokers, patients operated on for thrombosis, those who had 2 precipitating factors or more, and those who had a less than 30-day history of thrombosis. There was an inverse correlation between the elevated level of D-dimer and the duration of thrombosis by the moment of its identification (thrombus age). Conclusion. All patients who have experienced a venous thrombotic episode have various RFs for VTEE. The content of D-dimer exceeds the normal value in most patients with VTEE. Among the RFs studied, thrombus age is the most important factor associated with elevated D-dimer levels in patients with VTEE.
Terapevticheskii arkhiv. 2010;82(8):30-34
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Capabilities of sugar-lowering therapy in women with decompensated type 2 diabetes mellitus

Onuchin S.G., Elsukova O.S., Solovyev O.V., Onuchina E.L.


Aim: to comparatively evaluated the efficiency of various sugar-lowering therapy (SLT) options in patients with decompensated type 2 diabetes mellitus (T2DM). Subjects and methods. One hundred and eighty-two women who were over 55 years of age with a more than 3-5-year history of T2DM and more than one-year decompensation, abdominal obesity (AO), arterial hypertension, and concomitant treatment-matched were randomized into 4 groups: 1) metformin (n = 46); 2) a combination of metformin and gliclaside MB (n = 47); 3) metformin and insulin (n = 44); and 4) insulin (n = 45). A follow-up was 12 months. Results. As compared with the patients receiving insulin monotherapy, the patients taking metformin alone or in combination showed a more effective recovery of carbohydrate and lipid metabolic disturbances, diminished insulin resistance (IR), lowered blood pressure and albuminuria, reduced diastolic dysfunction, and a smaller cardiovascular risk. When metformin was used in combination with gliclaside (Group 2) for 12 months, there was the maximum IR reduction, an increase in insulin sensitivity, and better results in reaching the goal values of carbohydrate metabolism; there was left ventricular myocardial reverse remodeling. In all the groups, quality of life (SF-36v2) improved, reduced depression (CES-D) reduced; the greatest improvement of the mental component of health-related quality (SF-36v2) and the greatest satisfaction with treatment results (DTSO) were noted when metformin was given in combination with gliclaside MB. Conclusion. In patients having a more than 3-5-year history of T2DM in the presence of AO and IR, with a history of DM decompensation, the use of metformin in combination with gliclaside MB is more preferable, by effectively correcting IR, recovering the physiological profile of insulin secretion, and adequately controlling glycemia.
Terapevticheskii arkhiv. 2010;82(8):34-41
pages 34-41 views

Correlation of HbA1c and postprandial glycemia during a standard breakfast test in patients with type 2 diabetes receiving glibenclamide

Dreval A.V., Cheporeva O.N., Redkin Y.A., Misnikova I.V.


Aim. To analyze the effect of glibenclamide on carbohydrate metabolic parameters, glucose values after standard breakfast in particular, in patients with type 2 diabetes (T2D). Subjects and methods. Thirty patients aged 57.6±9.4 years with a 4.4±4.0-year history of T2D received glibenclamide in a daily dose of 10.9±4.4 mg in combination with diet therapy for 3 months. Venous plasma glycemia was determined before and at the end of the fasting test, 60 and 120 minutes after a standard breakfast test. The area under the glycemic curve was calculated using the trapezoidal method during the standard breakfast test. Out of all possible formulas reflecting a blood glucose increase in relative values during the test, there were two most acceptable formulas that were chosen for further calculations: 1) the contribution of postprandial glycemia exceeding fasting glycemia to postprandial glycemia exceeding 6.1 mmol/l (OS1/2); 2) that of postprandial glycemia exceeding the glycemia of 6.1 mmol/l to postprandial glycemia in the standard breakfast test (OS2/S). Results. Follow 3-month therapy, glycated hemoglobin (HBA1c) decreased from 8.7±1.8 to 7.0±1.0% (p < 0.0001), fasting plasma glucose reduced from 9.8±2.7 to 8.3+-1.7 mmol/l (p < 0.01); it decreased from 14.8±3.9 to 13.2+-3.3 mmol/l (p < 0.01) and from 13.3±3.6 to 11.1+-3.0 mmol/l (p < 0.02) 1 and 2 hours after the load test, respectively. There was a significant reduction in the total area under the glycemic curve (S) - from 1583.5±405.8 to 1375.7+-320.1 mmol/lmin. However, there were no significant changes. There was a significant increase in the relative value OS1/2 from 51.7±17.7 to 62.8±20.0% and a significant reduction in OS2/S. Analysis of the area in relative values (OS1/2 and OS2/S) obviates the ambiguousness of the results obtained when analyzing the area in absolute values. Conclusion. Glibenclamide treatment causes a statistically significant reduction in fasting and postprandial plasma glucose levels, glycated hemoglobin, and relative area values during the standard breakfast test.
Terapevticheskii arkhiv. 2010;82(8):41-44
pages 41-44 views

Impact of sibutramine (meridia) on body composition, peptide YY3-36 and serotonin levels in patients with exogenous constitutional obesity

Vlasova Y.Y., Ametov A.S.


Aim. To evaluate the impact of gradual weight loss and the positive effect of sibutramine on metabolic parameters and the levels of serotonin and neuropeptide YY3-36 levels in patients with exogenous constitutional obesity (ECO). Subjects and methods. The study included 36 patients (24 women and 12 men; mean age 37.56±0.9 years) with a verified diagnosis of ECO. The height, body weight, waist and hip circumference (WC and HC), and body mass index (BMI) were determined. Adipose tissue content was estimated by a bioimpedance method using an adipose mass analyzer. Serum peptide YY3-36 levels were measured by enzyme immunoassay and blood serotonin concentrations were estimated by high performance liquid chromatography with an electrochemical method. Results. 12-week sibutramine therapy caused a significant reduction in body weight, WC, HC, and BMI (p < 0.05) in all the patients. At the same time they were found to have a considerable body composition change (total body and visceral fat was decreased, total body water increased, and systemic metabolism was lowered). The mean peptide YY3-36 level was significantly decreased. Sibutramine did not affect the serum content of total serotonin in the sera of patients. Conclusion. Sibutramine used in the combined therapy in patients with ECO contributes to an effective and steady-state weight loss. Sibutramine treatment causes a reduction in total neuropeptide YY3-36, systemic metabolism, and adipose tissue at the expense of the visceral depot.
Terapevticheskii arkhiv. 2010;82(8):44-47
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Efficiency of cyclosporin A therapy in patients with myelodysplastic syndrome

Kokhno A.V., Parovichnikova E.N., Mikhailova E.A., Ustinova E.N., Kaplanskaya I.B., Dvirnyk V.N., Olshanskaya Y.V., Domracheva E.V., Savchenko V.G.


Aim. To evaluate the efficacy of cyclosporin A (CsA) in patients with myelodysplastic syndromes (MDS) and to identify determinants of a response to this therapy. Subjects and methods. The efficacy of CsA was evaluated in 52 patients (30 men and 22 women aged 16 to 74 years) with MDS. Thirty-two patients were given CsA as first-line therapy; 20 patients took the agent after prior therapy. CsA was used in a daily oral dose of 5 mg/kg. Its efficacy was evaluated following 3, 6, and 12 months. Actuarial survival was determined by the Kaplan-Meier method. Results. The efficacy of CsA used as first- and second-line therapy was 56 and 55%, respectively; complete remissions were achieved in 19 and 20% of cases. Baseline refractory anemia (RA) transformed to RA with excess blasts (RAEB) in 31% of cases; baseline RAEB did to acute myeloid leukemia in 34%. Overall survival was significantly associated with bone marrow (BM) blast cell percentage ( < 5% or > 5%; p = 0.0009), BM cellularity (hypoplasia and focal hypoplasia of hematopoiesis or BM hyperplasia; p = 0.03), focal polyclonal lymphoid infiltration in the BM (p = 0.01) and karyotype anomalies (low, moderate, and high risks; p = 0.001). Conclusion. CsA is the drug of choice in treating patients with MDS, including RA, RA with ringed sideroblasts, refractory cytopenia with multilineage dysplasia, with hypoplasia of hematopoiesis, with nodular polyclonal lymphoid infiltration in the BM, a normal karyotype or changes corresponding to a low or moderate IPSS risk.
Terapevticheskii arkhiv. 2010;82(8):48-53
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Role of antithymocyte globulin in reducing the incidence of complications after allogeneic hemopoietic cell transplantation

Zalyalov Y.R., Ganapiyev A.A., Golubovskaya I.K., Afanasyev B.V.


Aim. To evaluate the efficacy of antithymocyte globulin (ATG) used in conditioning modes before allogeneic hemopoietic cell transplantation (allo-HCT) and its effect in reducing the incidence of posttransplantation complications. Subjects and methods. The study assessed the results of 92 allo-HCTs depending on the presence or absence of ATG in conditioning modes, the doses of Atgam (60 mg/kg or more), the presence or absence of acute leukemia (AL) in remission before HCT. Results. In patients with AL in remission receiving ATG in conditioning modes (Atgam 60 mg/kg or thymoglobulin 7.5 mg/kg), overall three-year survival was 60%. Increasing the dose of Atgam up to more than 60 mg/kg resulted in higher transplantation-associated mortality (TAM) rates than did with the Atgam dose of 60 mg/kg (p < 0.01). Conclusion. Allo-HCT is the treatment of choice for patients with AL in the presence of an HLA-identical related or unrelated donor. The use of Atgam in a course dose of not more than 60 mg/kg or thymoglobulin 7.5 mg/kg in conditioning modes is associated with low TAM rates and higher overall survival in earlier-stage disease in complete clinical hematological remission as compared with those in patients with expanded-stage AL, rather than in AL in remission at the start of conditioning before HCT.
Terapevticheskii arkhiv. 2010;82(8):53-56
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Comparative evaluation of the safety and efficacy of etoricoxib and diclofenac on the upper gastrointestinal tract in patients with osteoarthrosis and rheumatoid arthritis (the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) study program)

Alekseyeva L.I.


The review gives and analyzes the data of a number of studies evaluating the safety and efficacy of nonsteroidal anti-inflammatory drugs on the upper gastrointestinal tract. Particular emphasis is laid on the results of the multinational etoricoxib and diclofenac arthritis long-term (MEDAL) study program. The randomized MEDAL study has shown that etoricoxib has more benefits than diclofenac.
Terapevticheskii arkhiv. 2010;82(8):57-62
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Inflammatory cardiomyopathy: state-of-the-art

Belyavsky E.A., Zykov K.A., Narusov O.Y., Masenko V.P., Skvortsov A.A., Shchedrina A.Y., Tereshchenko S.N.


Cardiomyopathy (CMP) is a major cause of early disability and death in young cardiac patients, remaining at the same time a little studied problem. The generally accepted term "dilated cardiomyopathy" is only a portrayal of morphological signs. As of now, the foreign literature most commonly uses the term "inflammatory cardiomyopathy" to denote CMP caused by viral and/or bacterial agents. Owing to the wide use of novel laboratory and instrumental diagnostic techniques, namely: molecular genetic and immunohistochemical studies and endomyocardial biopsy, there has been a possibility to conduct a more accurate and fuller study of inflammatory CMP. Despite the fact that the problems in nosology, classification, choice of the optimal diagnostic methods and management tactics for these patients.
Terapevticheskii arkhiv. 2010;82(8):62-71
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Impact of antidiabetic therapy on the risk of cardiovascular diseases and their complications in patients with type 2 diabetes mellitus

Ametov A.S., Pyanykh O.P., Chernikova N.A.


In Russia, diabetes mellitus afflicts 8 million people, 90% of them had type 2 diabetes mellitus (T2DM) and this figure is growing steadily. At the same time there is a rise in the incidence of macrovascular events (unstable angina pectoris, myocardial infarction). Coronary heart disease and its attack are a major cause of death in the developed countries, including Russia. To prevent chronic complications of DM is likely to be the most urgent task of not only modern diabetology, but also medical science as a whole. In this connection, of great value are the results of a few large international randomized controlled studies, the main objective of which was to evaluate the impact of the rate of blood glucose control on the incidence and outcomes of cardiovascular diseases in patients with T2DM.
Terapevticheskii arkhiv. 2010;82(8):71-75
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Use of inhaled tobramycin in patients with cystic fibrosis

Chermensky A.G., Gembitskaya M.E.


The results of a few studies evaluating the efficacy and safety of nebulized tobramycin solution used in patients with cystic fibrosis have been published to date. Pulmonary deposition of inhaled tobramycin and its lung produced concentrations are rather high (10-25 times greater than the minimum suppressing concentration) and systemic absorption is extremely low. The treatment makes it possible to improve external respiratory function, to lower the colonization of the bronchi with Pseudomonas aeruginosa, and, in many cases, to achieve its eradication. Inhaled tobramycin reduces the sputum level of inflammatory cytokines in patients with cystic fibrosis, which slows down irreversible lung changes. Inhaled antibacterial therapy results in a reduction in the number of exacerbations, the frequency of admissions, and the need for systemic antibiotics.
Terapevticheskii arkhiv. 2010;82(8):76-78
pages 76-78 views

Fedor Ivanovich Komarov (k 90-letiyu so dnya rozhdeniya)

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Terapevticheskii arkhiv. 2010;82(8):79-80
pages 79-80 views

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