Vol 83, No 4 (2011)

Articles
Microcirculatory disorders in hypertension, atherosclerosis, diabetes mellitus
Gogin E.E., Gogin E.E.
Abstract
Fundamental investigations of the role of the endothelium and cell periphery in regulation of vascular tonicity in the last decade of the XX century brought a radical revision of the former conception of circulation. It was discovered that distribution of blood in the arteries depends on operational requirements of the tissues and organs, it is not determined by integrating mechanisms of neuroendocrine regulation. Problems of hemodynamics and microcirculation give rise to much discussion now because neurogenic hypophysis of cardiovascular disease development still has many supporters among medical profession. Progressive disturbances of circulation and hemodynamics may be produced by diseases known as nosological entities for many years. Arterial hypertension often plays a leading role in common polymorbid combinations. It is important to include in basic treatment additional modalities taking consideration of existing at the moment leading risk factors. This involves an individual approach to choice of therapy.
Terapevticheskii arkhiv. 2011;83(4):5-13
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Multiple myeloma: innovations in diagnosis
Chovdkhuri P.R., Kryuchkov M.I., Zinina E.A., Morozov S.P., Brodetskiy B.M., Chovdkhuri P.R., Kryuchkov M.I., Zinina E.A., Morozov S.P., Brodetsky B.M.
Abstract
Multiple myeloma (MM) belongs to the group of paraproteinemic hemoblastosis. Its clinical picture varies but the main clinical presentation is bone tumor proliferation resultant from enhanced resorption of tumor tissue related to bone marrow infiltration with plasmic cells, activation of osteoclasts. This leads to marked ossalgic syndrome and pathological bone fragility. MM often runs with nephropathy, immunodepression, hemopoietic disorders. Non-specific clinical manifestations of MM cause difficulties in making accurate diagnosis.Our clinic introduces innovative high-tech methods of examination including MR tomography of the body which detects the disease at early stages and, finally, allows us to prolong the patient's life.
Terapevticheskii arkhiv. 2011;83(4):14-17
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Primary lymphoma of the heart: difficulties in diagnosis and treatment
Blagova O.V., Nedostup A.V., Dzemeshkevich S.L., Sinitsyn V.E., Sedov V.P., Gagarina N.V., Parshin V.D., Chernyy S.S., Noskova M.V., Troitskaya M.P., Blagova O.V., Nedostup A.V., Dzemeshkevich S.L., Sinitsyn V.E., Sedov V.P., Gagarina N.V., Parshin V.D., Cherny S.S., Noskova M.V., Troitskaya M.P.
Abstract
Primary lymphoma of the heart (non-Hodgkin's lymphoma primarily of B-cells affecting first the heart and pericardium) is a rare disease which accounts for 1.3-2.0% of all primary tumors of the heart. A case is reported of a 43-year-old male patient with a cardioverter-defibrillator implanted at the age of 38 years for management of ventricular tachycardia paroxysms and AB-block of the second-third degree. The patient also had hypertrophic cardiomyopathy, moderate pressure gradient on the pulmonary artery valve and pericardial effusion. Later he had two cardiac tamponades (serous punctuate). From the age of 42 years breathlessness, right ventricular wall thickness, right heart pressure and pulmonary artery pressure aggravated. The patient has undergone ballon plastic surgery of the pulmonary artery valve. At the age of 43 computed tomography detected massive tumor of the heart and mediastinum first diagnosed as sarcoma but later specified as lymphoma. Endobronchial biopsy specimens contained the tissue of diffuse large B-cell lymphoma, the liver and lymph nodes were also involved. After the first course of effective polychemotherapy (CHOP) the patient died of mesenterial thrombosis. Diagnostic difficulties and problems of treatment policy are discussed.
Terapevticheskii arkhiv. 2011;83(4):17-23
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Chronodiagnostic potentialities of the symbolic dynamics method
Gurov Y.V., Zaguskin S.L., Gurov Y.V., Zaguskin S.L.
Abstract
Aim. To assess diagnostic potential of cardiac rhythm symbolic dynamics. Material and methods. PhysyoNet base data on ECG heart rhythm for 24 hours were analysed by characteristics of the symbolic lines: size of vocabularies and entropic properties of symbol distribution in the lines. The following ECGs were analysed: 54 ECGs of healthy individuals with normal sinus rhythm aged 28.5-76 years; 44 ECGs of patients with congestive cardiac failure aged 34-79 years; 84 ECGs of patients with cardiac fibrillation aged 34-79 years; 19 ECGs of patients with sudden cardiac death syndrome aged 34-79 years. Results. The index of variety of cardiac rhythm regulation is proposed which is effective not only for analysis of 24-h but also of 40-60 min rhythmograms. Conclusion. The quantitative analysis of symbolic dynamics can be used for differential chronodiagnosis of different cardiac diseases. Application of words which vary by length allows examination of rhythms with different time scale, detection and comparison of hierarchical desynchronization.
Terapevticheskii arkhiv. 2011;83(4):23-26
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Novel endoscopic terminology: NBI visualization
Kreymer V.D., Tyurin V.P., Kogan E.A., Kreimer V.D., Tyurin V.P., Kogan E.A.
Abstract
Aim. To develop new criteria of gastric and duodenal mucosa image assessment using endoscopic system for narrow band imaging (NBI). Material and methods. Endoscopic and morphological findings were compared in 460 patients with different chronic diseases of the stomach and duodenum. Esophagogastroduodenoscopy was made according to the standard technique by the gastroduodenoscope EVIS EXERA-II GIF H180 (Olympus, Japan) with NBI-system. Biopsy material was studied by standard pathomorphological techniques. Results. The novel system of the visual picture evaluation during conduction of endoscopic investigations in monochromatic light provides higher significance of identification of inflammatory and destructive processes in mucosa including foci of structural alterations, their location and extent. Conclusion. We propose a protocol for description of the endoscopic picture in conduction of examinations with application of the NBI-system of visualization in monochromatic light. It can help physicians to correctly estimate the image and interpret the detected changes.
Terapevticheskii arkhiv. 2011;83(4):27-30
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Clinical significance of intravital morphological investigation of the liver
Khomeriki S.G., Yakimchuk G.N., Golovanova E.V., Homeriki S.G., Yakimchuk G.N., Golovanova E.V.
Abstract
Aim. To demonstrate great importance of intravital morphological examination of the liver for differential diagnosis of chronic diffuse diseases (CDD) of the liver. Material and methods. A complete clinical examination, needle or intraoperative biopsy of the liver were made in 1045 patients with chronic diseases of the liver. Structural features of hepatic tissue were studied histologically. Variational statistics was used for analysis. Results. Viral markers were detected in 373 patients (HCV in 53%, TTV in 10%, HBV in 16%, HGV in 6%, CMV in 3%). Chronic hepatitis (CH) was caused by combined viral infection in 12% cases. CH variants were verified morphologically in 64% patients with provisional diagnosis CH. Objective evaluation of structural changes severity rested on algorithms of semiquantitative determination of the index of histological activity and fibrosis index. Hepatic cirrhosis of viral or alcohol etiology was detected in 4.8%, primary biliary cirrhosis - in 11.2%, non-alcoholic fatty disease of the liver - in 11.2% patients. Impaired glucose tolerance is an essential factor predisposing to non-alcohol fatty disease of the liver. Detection of vacuole-like nuclei in periportal hepatocytes is an early morphological sign of the fatty disease. Three percent of the patients had signs of minimal portal cholangitis. This correlated with TTV detection. Conclusion. Life-time morphological examination of the liver specifies activity and stage of the process in chronic hepatitis, confirms or detects abnormalities in hepatic architectonics, identifies clinically significant changes in cellular and intercellular components of hepatic tissue, detects and verifies rare hepatic affection. Such information is of importance for optimization of treatment policy and improvement of prognosis in CDD of the liver.
Terapevticheskii arkhiv. 2011;83(4):30-36
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Results of 24-h pH monitoring in patients with gastroesophageal reflux disease before and after fundoplication
Yanova O.B., Vasnev O.S., Yanova O.B., Vasnev O.S.
Abstract
Aim. To study informative value of 24-h pH monitoring in registration of gastroesophageal and duodenogastroesophageal reflux (GER, DGER) in patients with gastroesophageal reflux disease (GERD) before and after surgical treatment. Material and methods. A total of 39 GERD patients after laparoscopic fundoplication entered the study: 12 (39%) males and 27 (61%) females, mean age 47.6±3.2 years.pH monitoring was made with domestic device Gastroscan-24 before operation and one year after it. Esophagogastroscopy and polypositional roentgenoscopy of the upper gastroduodenal tract were made also before operation and after 1-year follow-up. Results. Before operation, mean pH in the gastric body was 1.7±1.28, De Meester index 40.4±8.91, esophageal acidity index (EAI) 22.3±1.59, the number of acid GER 59.2±9.41, number of DGER 14,3 ± 3,47. After laparoscopic fundoplication - 3.3±1.52, 8.7±5.71 (p < 0.05), 2.5±0.62 (p < 0.05), 24.4±8.6 (p < 0.05), 6.5±3.63, respectively. Five patients (12.8%) examined before the operation had clinicoendoscopic picture of GERD, but normal values of De Meester index and EAI. Conclusion. 24-h pH monitoring can estimate both gastroesophageal and duodenoesophagogastric refluxes, but esophageal and gastric pH monitoring only are not sufficient for decision on treatment policy. Such decision should be taken individually for each patient after the analysis of the results of complete clinical examination, symptoms and the disease history.
Terapevticheskii arkhiv. 2011;83(4):36-39
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Changes in orthogonal ECG in hypertensive patients taking different antihypertensive therapy
Sakhnova T.A., Blinova E.V., Ryabykina G.V., Shutova L.I., Chikhladze N.M., Martynyuk T.V., Chazova I.E., Sakhnova T.A., Blinova E.V., Ryabykina G.V., Shutova L.I., Chikhladze N.M., Martynyuk T.V., Chazova I.E.
Abstract
Aim. To ascertain changes in orthogonal ECG in hypertensive patients taking different antihypertensive treatment. Material and methods. Orthogonal ECG parameters and those of 24-h blood pressure monitoring (BPM) were examined before and after antihypertensive treatment with different drugs in 95 hypertensive patients aged 47±1 years. Of them, 14 patients received trandolapril+verapamil SR for 2 months, 13 patients - candesartan for 3 months, 25 patients - ramipril for 5 months, 26 patients - carvedilol for 4 months, 10 patients - atenolol for 8 months, 7 patients - doxasozine for 5 months. Results. 24-h BPM parameters improved in all the groups . Initially, conventional ECG evidence on left ventricular hypertrophy was not seen in 86% patients. Dynamics of orthogonal ECG showed that parameters which increase in left ventricular hypertrophy decrease in response to treatment in patients with baseline values above the median. Parameters G and Gx,which in left ventricular hypertrophy diminish, rise significantly in patients with baseline values under median due to therapy. Treatment with impact on renin-angiotensin system reduced voltage parameters of orthogonal ECG, improved G characterizing repolarisation. Treatment with adrenoreceptors blockers reduced IADI. Conclusion. The analysis of parameters of orthogonal ECG reveals positive dynamics in response to treatment in patients with insignificant changes on ECG in short follow-up. Drugs of different groups change different parameters of orthogonal ECG.
Terapevticheskii arkhiv. 2011;83(4):39-42
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Echocardiographic assessment of left ventricular myocardial deformation by automatic functional image in patients with sigmoid interventricular septum
Alekhin M.N., Zvereva L.V., Polyakova T.Y., Alekhin M.N., Zvereva L.V., Polyakova T.Y.
Abstract
Aim. To assess a new method of automatic functional image for estimation of maximal systolic longitudinal strain of left ventricular (LV) myocardium in patients with sigmoid interventricular septum (IVS) with normal LV ejection fraction. Material and methods. Maximal systolic longitudinal strain was compared in patients with sigmoid IVS (SIVS) and in 21 patients of the control group. Results. Compared to controls, patients with SIVS have significantly greater global longitudinal systolic LV strain in two septal segments in the region of sigmoid-shape IVS. Conclusion. Local aggravation of maximal systolic longitudinal LV myocardium strain in SIVS zone can be one of the causes of dynamic obstruction of the efferent LV tract.
Terapevticheskii arkhiv. 2011;83(4):43-46
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Outpatient prophylaxis and treatment of arterial hypertension with application of mobile telephone systems and internet techniques
Kiselev A.R., Shvarts V.A., Posnenkova O.M., Gridnev V.I., Dovgalevskiy P.Y., Oshchepkova E.V., Evstifeeva S.E., Kiselev A.R., Shvarts V.A., Posnenkova O.M., Gridnev V.I., Dovgalevsky P.Y., Oschepkova E.V., Evstifeeva S.E.
Abstract
Aim. To compare clinical efficacy of standard outpatient follow-up of hypertensive patients with efficacy of such follow-up with application of internet techniques and mobile telephone systems (ITMTS). Material and methods. Two groups of hypertensive patients were examined: group 1 (n = 97, 45% females, age 49±11 years) on one-year ITMTS follow-up; group 2 (n = 102, 50% females, age 51±11 years) on standard one-year follow-up. Clinical efficacy was assessed by the rate of achievement and maintenance of target blood pressure, dynamics of modifiable risk factors (smoking, obesity) for a year. Results. Withdrawal in group 1 was 36%, target blood pressure was achieved in 77% patients vs 12% in group 2 (p < 0.001). Conclusion. Introduction of ITMTS technologies into outpatient clinics activity considerably raises efficacy of outpatient treatment of hypertensive patients.
Terapevticheskii arkhiv. 2011;83(4):46-52
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Efficacy and safety of the first made in Russia alpha, beta long-acting adrenoblocker proxodolol in patients with arterial hypertension of the second degree
Belyaeva S.A., Belyaeva S.A.
Abstract
Aim. To study efficacy and safety of a new dose and dosage form of proxodolol - a beta-adrenoblocker with alpha1-adrenoblocking activity - in patients with moderate arterial hypertension (AH). Material and methods. A total of 60 patients with verified diagnosis of essential AH of the second degree were randomized into two groups: group 1 (n = 40) received proxodolol, group 2 (n = 20) was given carvedilol. The trial lasted for 89 days. Results. The trial demonstrates that proxodolol is highly effective and safe in the treatment of AH. Conclusion. Proxodolol is effective and safe in hypertension, in a dose 120 mg its activity is the same as carvedilol in a dose 25 mg.
Terapevticheskii arkhiv. 2011;83(4):52-55
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A protective effect of Gly272Ser polymorphism of GNB3 gene in development of essential hypertension and its relations with environmental hypertension risk factors
Polonikov A.V., Solodilova M.A., Ivanov V.P., Shestakov A.M., Ushachev D.V., Vyalykh E.K., Vasil'eva O.V., Polyakova N.V., Antsupov V.V., Kabanina V.A., Kupriyanova Y.S., Bulgakova I.V., Kozhukhov M.A., Tevs D.S., Polonikov A.V., Solodilova M.A., Ivanov V.P., Shestakov A.M., Ushachev D.V., Vyalykh E.K., Vasilyeva O.V., Polyakova N.V., Antsupov V.V., Kabanina V.A., Kupriyanova Y.S., Bulgakova I.V., Kozhukhov M.A., Tevs D.S.
Abstract
Aim. To study associations of C825T (rs5443) and G272S (rs16932941) polymorphisms of GNB3 gene in Russian population of the Central Chernozem region with essential hypertension (EH) risk; to elicit the role of environmental risk factors in realization of EH predisposition in this gene genotypes carriers. Material and methods. We studied DNA samples obtained from 205 EH patients and 207 healthy individuals. EH patients were treated in Kursk hospitals. Genotyping of GNB3 gene polymorphisms was conducted by polymerase chain reaction and restriction analysis. Results. Prevalence of 825T allele of GNB3 gene in EH patients and healthy individual was 0.334 and 0.295, respectively, of 272S allele - 0.037 and 0.058, respectively. We found no significant differences by prevalence of genotypes of gene GNB3 polymorphisms C825T and G272S in EH patients and healthy individuals. Non-smoking carriers of 272GS genotype had a low risk of EH (OR 0.42 in 95% CI from 0.18 to 0.97; p = 0.04). Smokers had no protective effect of this genotype. The protective effect of 272GS genotype was also found in individuals with low or moderate alcohol drinking habits (OR 0.29 in 95% CI from 0.11 to 0.77, p = 0.02) and in individuals without chronic exposure to stress (OR 0.29 in 95% CI from 0.09 to 0.91, p = 0.04). In contrast, hard drinkers and patients exposed to chronic stress had no protective effect of heterozygous genotype 272GS of gene GNB3. Conclusion. G272S polymorphism of GNB3 gene can be considered as a new genetic marker of predisposition to EH. The protective effect depends of environmental factors associated with high risk to develop EH.
Terapevticheskii arkhiv. 2011;83(4):55-60
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Clinical statistics and effectiveness of different treatments of idiopathic thrombocytopenic purpura
Kovaleva L.G., Pustovaya E.I., Safonova T.I., Ryadnenko A.A., Kolosova E.N., Kovaleva L.G., Pustovaya E.I., Safonova T.I., Ryadnenko A.A., Kolosova E.N.
Abstract
Aim. To ascertain efficacy of modern treatment methods in idiopathic thrombocytopenic purpura (ITP), to characterize basic indications for administration of these methods; perspective trends in ITP therapy. Material and methods. The article presents 20-year experience in observation and treatment of 1000 ITP patients gained from 1988 by the department of standardization of blood disease treatment methods on the basis of a consultative and outpatient department of Hematological Research Center. The results were assessed by conventional ITP treatment lines. Results. First-line therapy - glucocorticoids - provided remission in 70% patients, long-term (60 months and longer) in 14%, prednisolone resistance was in 19% patients.Intravenous immunoglobulin provided a rapid hemostatic effect (in1-2 days) in all the patients. A positive response to treatment was seen in 86% patients but it was short-term (for a year and longer in 27%, resistance to the drug - 14%). Second line treatment -splenectomy - is the most effective treatment: 80% remission, 32% patients had remission for longer than 60 months. Resistance occurred in 6% patients. Ineffectiveness of treatment in 20% patients stimulated the search for new pathogenetic treatment among synthetic analogues of thrombopoietin. Clinical trials proved high efficacy of two of them - eltrombopag and romiplostim (86-87% response), possible maintenance of remission in long-term interrupted administration of low doses. Conclusion. Modern ITP treatment allows a complete management of hemorrhagic syndrome and deep thrombocytopeny in 80% patients with provision of good quality of life and ability to work. Introduction into clinical practice of thrombopoietin analogues improves treatment results including in 20% patients resistant to all treatments in the absence of marked side effects even in long-term 3-year administration of such medication.
Terapevticheskii arkhiv. 2011;83(4):60-65
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Changes in paradoxical emboly readiness in divers with open oval window of the interatrial septum
Onishchenko E.F., Berezina N.N., Onischenko E.F., Berezina N.N.
Abstract
Aim. To study development of paradoxical emboly readiness (PER) in the process of diving. Material and methods. Examination and observation covered 46 inexperienced divers (beginning divers - BD), 51 experienced divers (diving experience more than 3 years, ED) and 98 healthy individuals not interested in diving. The examinees were follow-up for 20 years. All of them had no organic cardiovascular pathology. PER was detected by the method of imitation modeling of underwater emboly using prolonged infusion contrast echocardiography (PICE) with hydrogen peroxide solution. The intensity of right-left interatrial bypass (RLIAB) was determined by the number of microblebs penetrating in PICE in the left heart. In the BD group PICE was made each 3 years of diving experience, in ED group - each3-5 years of further diving experience. Results. Diving leads to activation of RLIAB, the number of divers with PER increases. Bypass and PER intensity grows in BD group. In ED group PER increased but RLIAB changed insignificantly. Conclusion. Our investigation confirms unfavourable effects of diving on RLIAB of blood in persons with open oval window (OOW) enhancing PER. Further investigations should be made on effects of diving on hemodynamic disorders due to OOW.
Terapevticheskii arkhiv. 2011;83(4):66-69
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B-cell lymphoma in a woman with chronic hepatitis C and mixed cryoglobulinemia of type 2
Ignatova T.M., Milovanova S.Y., Chernova O.A., Bayzhanova Z.Z., Ignatova T.M., Milovanova S.Y., Chernova O.A., Baizhanova Z.Z.
Abstract
A report is presented of a rare case of B-cell non-Hodgkin"s lymphoma and severe exacerbation of cryoglobulinic vasculitis which developed in a female patient with chronic hepatitis C four years after achievement of a persistent virusological response to antivirus treatment. Causes of a specific course of the disease and development of the tumor in the absence of HCV in blood serum are discussed: latent HCV-infection in immune cells with persistent antigenic stimulation of B-lymphocytes, possibility of HCV-independent lymphoproliferation.
Terapevticheskii arkhiv. 2011;83(4):69-71
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Renin-angiotensin-aldosteron system: evolution of views from renin discovery to nowadays. Perspectives of therapeutic block
Shestakova M.V., Shestakova M.V.
Abstract
Recent revolution in the knowledge about structure, physiological and pathophysiological effects of renin-angiotensin-aldosteron system (RAAS) took place recently when it was discovered that local synthesis of all the RAAS components occurs in target organs and their tissues (the heart, kidneys, vessels, brain tissues). It was found that besides classic RAAS acting via activation of angiotensin II (Ang-II) and its receptors, there is an alternative RAAS opposed to atherogenic potential of Ang-II. Renin and prorenin are shown to have both enzymatic and hormonal activities. Wider understanding appeared of extrarenal effects of aldosteron, its non-genomic activity. The above discoveries open new opportunities for pharmacological regulation of RAAS activity, which enables more effectively correct overactivity of this system in organs at risk of negativeAng-II impact.
Terapevticheskii arkhiv. 2011;83(4):71-77
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2011 calendar of anniversaries in the history of therapy
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Abstract
Terapevticheskii arkhiv. 2011;83(4):77-80
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