Vol 85, No 8 (2013)

Editorial
Fundamental medicine as a basis of innovations in medical practice
Chazov E.I.
Terapevticheskii arkhiv. 2013;85(8):6-7
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New clinical and organizational approaches to preventing cardiovascular diseases in the primary health care system
Boĭtsov S.A., Kalinina A.M., Ipatov P.V.
Abstract
The paper deals with the justification and description of clinical and organizational approaches to preventing cardiovascular diseases (CVD) in the primary health care system (PHCS) under the present conditions of health care modernization in Russia. It formulates the basic directions of systematic measures in integration strategies for the prevention of noncommunicable diseases (mainly CVD) at a federal level, in which practical measures are presented to improve a system for the early detection of high-risk individuals and to carry out measures for risk factor correction in PHCS, i.e. to implement high-risk strategies, including clinical and organizational approaches to reconstituting the medical prevention infrastructure in PHCS. This is favored by the new normative documents adopted by the Ministry of Health of Russia on the follow-up and prophylactic medical examinations of the adult population. The paper substantiates the objective need for such examinations and characterizes the main clinical and organizational approaches promoted in medical examinations, which is aimed at introducing the current science-based and economically expedient methods in the real practice of PHCS for the early identifications of atherosclerosis-induced major CVDs and, what is particularly important, a risk for their development. Prophylactic counseling as a compulsory component is first being introduced in medical examination procedures. The key clinical and organizational principle of effective CVD prevention in public health is the implementation of the relationship and continuity of preventive measures, which becomes realistic with the adoption of new regulations of clinical examinations, prophylactic medical examinations, and follow-ups. The improvement of CVD prevention is associated not only with the introduction of organizational innovation changes, but also with the need to create a prevention ideology in physicians at all levels. It is emphasized that a comprehensive approach and all integrated CVD prevention strategies both at the population level and in the PHCS facilities are the most efficient and cost-effective procedure to reduce premature deaths from CVD in the population and to improve the demographic situation in our country.
Terapevticheskii arkhiv. 2013;85(8):8-13
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Teaching therapeutic disciplines: vectors of modernization
Mukhin N.A., Maev I.V., Svistunov A.A., Fomin V.V.
Abstract
The paper discusses approaches to improving educational technologies in therapeutic disciplines taught at higher medical education institutes according to the basic curricula in Therapeutics (060101).
Terapevticheskii arkhiv. 2013;85(8):14-19
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Pharmacotherapy for rheumatoid arthritis in the early 21st century: Russian and international experience
Nasonov E.L., Karateev D.E., Lukina G.V.
Abstract
The paper summarizes the data of international and Russian studies concerning current approaches to the pharmacotherapy of rheumatoid arthritis. Particular emphasis is placed on the substantiation of the treat-to-target concept, on the efficacy and safety of genetically engineered biological agents, including the inhibitors of tumor necrosis factor, interleukin-6 receptors, T-lymphocyte co-stimulation, and anti-B-cell therapy.
Terapevticheskii arkhiv. 2013;85(8):20-28
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Efficiency of treatment of adult patients with acute T-lymphoblastic leukemia according to the ALL-2009 protocol of the Russian Acute Leukemia Study Group
Parovichnikova E.N., Kliasova G.A., Troitskaia V.V., Sokolov A.N., Kuz'mina L.A., Mendeleeva L.P., Kravchenko S.K., Ryzhko V.V., Bondarenko S.N., Kariakina E.A., Baranova O.I., Lapin V.A., Ryl'tsova T.V., Gavrilova L.V., Pristupa A.S., Kaporskaia T.S., Zagoskina T.P., Samoĭlova O.S., Klimovich A.V., Konstantinova T.S., Vopilina N.A., Skamorina O.P., Kaplanov K.D., Zinina E.E., Domracheva E.V., Gal'tseva I.V., Kulikov S.M., Savchenko V.G.
Abstract
AIM: To present the results of treatment in adult patients with acute T-lymphoblastic leukemia (T-ALL) according to the ALL-2009 protocol of the Russian Acute Leukemia Study Group, the basic principle of which is continuation of cytostatic treatment, early switch from prednisolone to dexamethasone, and long-term use of L-asparaginase/MATERIAL AND METHODS: The results of diagnosis and treatment were analyzed in 70 patients with different immunological variants of T-ALL treated in the Russian multicenter trial/RESULTS: Out of the 70 patients with T-ALL, its early immunotype was determined in 32 (45.7%) cases, the thymic and mature immunotypes were found in 31 (44.3%) and 7 (10%) cases, respectively. The median age of the patients with T-ALL was 28 (ranged from 15 to 54) years; men were twice more than women (48 and 22, respectively). Bone marrow lesion was noted in all the patients with early T-ALL and in 80% of the patients with thymic and mature T-ALL. The enlarged mediastinum was significantly more frequently detected in mature T-ALL (100%) than in its early (53.4%) and thymic (60.7%) variants. Therapeutic effectiveness was evaluated in 58 patients. An analysis was made in January 2013. Induction therapy resulted in complete remission in 49 (84.5%) patients. The refractory course of the disease was recorded in 5 (8.6%) cases; early death was in 4 (6.9%). The rate of complete remission in thymic T-ALL, unlike in the early (72%) and mature (71.4%) variants, was significantly higher (100%) due to the absence of resistant forms and early mortality. Moreover, it should be noted that only the patients with early T-ALL (16%) died during the induction phase. In the patients with different variants of T-ALL, the overall and relapse-free survival rates were not significantly different, accounting for 67.2 and 76.2%, respectively. Multivariate analysis revealed no prognostically unfavorable factors that determined long-term results/CONCLUSION: The ALL-2009 protocol is reproducible in any regions of the Russian Federation and highly efficient in treating patients with T-ALL.
Terapevticheskii arkhiv. 2013;85(8):29-34
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Crohn's disease: on the occasion of the 80th anniversary of description
Parfenov A.I.
Abstract
In 1932, Burrill Bernard Crohn, Leon Ginzburg, and Gordon Oppenheimer published the paper "Regional ileitis: a pathological and clinical entity" first describing terminal ileitis that took further its name from B. Crohn. Crohn's disease (CD) is a recurring systemic inflammatory disease affecting the gastrointestinal tract (GIT) with extraintestinal manifestations and systemic immune disorders. Its etiology is unknown; the pathogenesis is associated with congenital impairments in the intestinal barrier and immune response to diversified symbiotic bacteria. The classification and the specific features of the natural history of CD are presented; the possibilities of new methods for its diagnosis and treatment are shown. Its new treatment goals are formulated; these are to achieve complete recovery of the involved bowel wall; to use confocal endoscopy, ultrasonography, magnetic resonance imaging, computed tomography, positron emission tomography, and the biomarkers C-reactive protein, fecal calprotectin, and lactoferritin. Algorithms for CD diagnosis and treatment using anticytokine agents and mesenchymal stromal stem cells are given.
Terapevticheskii arkhiv. 2013;85(8):35-42
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Chronic obstructive pulmonary disease and comorbidities
Chuchalin A.G.
Abstract
In current clinical practice, there are increasing numbers of patients in whom chronic obstructive disease is concurrent with three diseases: diabetes mellitus, coronary heart disease, and arterial hypertension. The concomitance of these socially significant diseases reflects a new stage of diseases of this century.
Terapevticheskii arkhiv. 2013;85(8):43-48
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A combination of dipeptidyl peptidase-4 inhibitor and metformin in the treatment of patients with type 2 diabetes mellitus: effective control of glycemia, weight, and quantitative body composition
Shestakova M.V., Sukhareva O.I., Chernova T.O., Shmushkovich I.A., Aleksandrov A.A., Il'in A.V., Dedov I.I.
Abstract
AIM: To study the impact of intensified therapy with the dipeptidyl peptidase-4 (DPP-4) inhibitor vilagliptin or sulfonylurea (SU) on the control of glycemia, weight, and quantitative body composition in patients with type 2 diabetes mellitus (DM-2) who have failed to achieve compensation during metformin monotherapy/MATERIAL AND METHODS: Forty patients (mean age 55.0 (range 53.0-60.7) years; disease duration 2.0 (range 1.1-5.0) years) with poor glycemic control (7%
Terapevticheskii arkhiv. 2013;85(8):49-55
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Stepwise treatment in patients with isolated thermal inhalation injury
Degtiareva S.A., Shmelev E.I., Smirnov S.V., Brygin P.A.
Abstract
AIM: To evaluate the efficiency of stepwise treatment in patients with isolated thermal inhalation injury (TIJ)/MATERIAL AND METHODS: The study enrolled 101 patients with isolated TIJ. A study group (n=56) was treated at the Pulmonology Department after managing at the Burn Center (BC); a control group (n=45) received no systematic treatment after discharging from BC. The magnitude of respiratory symptoms (according to the rating system) and external respiratory function (ERF) was evaluated and fibrobronchoscopy was made in all the included patients at their discharge from BC. On admission to the Pulmonology Department, the study group patients underwent evaluation of the magnitude of respiratory symptoms, EFR, and lung diffusing capacity, determination of blood gas composition and exercise tolerance, and chest computed tomography. Respiratory symptoms, ERF, and exercise tolerance were evaluated in all the included patients one month after hospital discharge/RESULTS: Examination at the Pulmonology Department established preserved respiratory manifestations in patients who had to continue therapy. The use of Β2-agonists or inhaled steroids used in combination or alone need, mucoregulators or antibiotics revealed the efficiency of a stepwise approach to managing patients with TIJ/CONCLUSION: There is evidence that it is expedient to perform two-stage treatment in patients with TIJ, by transferring them from BC to a specialized pulmonology hospital, which substantially enhances the efficiency of medical care for this contingent of patients.
Terapevticheskii arkhiv. 2013;85(8):56-59
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Extracorporeal photopheresis in the treatment of patients with refractory chronic graft-versus-host disease after allogeneic bone marrow transplantation
Bykova T.A., Kozlov A.V., Stancheva N.V., Semenova E.V., Kulagina I.I., Bondarenko S.N., Vavilov V.N., Morozova E.V., Zubarovskaia L.S., Afanas'ev B.V.
Abstract
AIM: To evaluate the efficiency of extracorporeal photopheresis (ECP) in the treatment of patients with refractory chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT)/MATERIAL AND METHODS: The study included 49 patients aged 2 to 55 years. Allo-HSCT was carried out in 38 (79%) patients with acute leukemias, 5 (10%) with chronic leukemias, 4 (8%) with myelodysplastic syndrome/myeloproliferative disease, and 2 (3%) with other hematologic diseases. The patients included in the study had glucocorticosteroid (GCS)-refractory disseminated cGVHD or a history of severe complications from GCS therapy/RESULTS: When evaluating the efficiency of therapy, its response was recorded in 37 (77%) cases; the best results were obtained in patients with hepatic (82%), mucosal (76%), and skin (74%) lesions. The mean severity according to the cGVHD Working Group, National Institutes of Health, and a platelet level of more than 100·109/l were defined as factors improving a therapy response. In the patients receiving ECP, the overall survival was 70%. The latter was higher in the group of patients who had responded to ECP therapy without involving the gastrointestinal tract in the cGVHD process and in those receiving a combination of ECP and other immunosuppressive drugs/CONCLUSION: ECP is an effective treatment for patients with refractory cGVHD, it may be used in those with a history of severe complications from GCS therapy. ECP allows the dose of GCS to be reduced to the point of complete discontinuation.
Terapevticheskii arkhiv. 2013;85(8):60-68
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Role of splenectomy in the treatment of myelofibrosis
Melikian A.L., Kolosova L.I., Sokolova M.A., Kovrigina A.M., Silaev M.A., Giliazitdinova E.A., Gemdzhian É.G., Karagiulian S.R.
Abstract
AIM: To evaluate the clinical and hematologic efficiency of splenectomy (SE) in patients with myelofibrosis (MF) resistant to conventional traditional treatment/MATERIAL AND METHODS: Case histories were retrospectively analyzed in 52 MF patients who had been followed up at the Hematology Research Center, Ministry of Health of the Russian Federation, in 2004 to 2012 and undergone therapeutic SE (47 patients with primary myelofibrosis, 4 with postpolycythemia myelofibrosis, and 1 with postthrombocythemia myelofibrosis). The mean age was 47 years at diagnosis and 53 years before surgery. The patients younger than 50 years of age constituted 60%. Massive and giant splenomegaly was detected in 37 (71%) patients. The spleen weighing 0.9 to 2.9 and 3 to 7 kg was removed in 15 (29%) and 35 (67%) patients, respectively. In 2 cases, the weight of the removed spleen was as much as 10 and 11 kg/RESULTS: By the moment of SE, the disease duration averaged 76 (from 1 to 240) months. Twenty-one (40%) patients developed perioperative complications, including bleeding (15%), thrombosis (11.5%), and infectious complications (13.5%). There were no deaths from surgical interventions in the intra- and early postoperative periods. In more than 80% of the patients after SE, their general condition improved and the symptoms of intoxication disappeared; in the majority of patients, the therapeutic effect lasted about 2 years. In the follow-up period, 33 (63%) patients died; the time to death averaged 27 (1-84) months following SE. The causes of death were blast transformation in 27 (82%) patients and comorbidity in 6 (18%); 19 (37%) patients with an average post-SE follow-up of 37 (4-72) months continued hydroxyurea treatment. The median survival after SE was equal to 3 years; the median overall survival was 11 years/CONCLUSION: SE is effective palliative care with an acceptable level of occurring complications for individual patients with MF. Contraindications to SE as blast crisis and severe comorbidities should be strictly taken into account.
Terapevticheskii arkhiv. 2013;85(8):69-76
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Clinical efficiency of transfusion of pathogen-inactivated platelet concentrates
Nakastoev I.M., Grachev A.E., Gemdzhian É.G., Tsyba N.N., Zhuravlev V.V., Krechetova A.V., Kastrikina I.S., Vatagina E.A., Ryzhko V.V., Gorodetskiĭ V.M.
Abstract
AIM: To evaluate the effect of pathogen-inactivated platelet concentrates (PIPC) on posttransfusion platelet increments, hemorrhagic syndrome relief, and transfusion intervals/MATERIAL AND METHODS: This prospective study included 29 hemoblastosis patients (13 women, 16 men), median age 38 years (20-66 years). Pathogens were inactivated by the photodynamic method using the Intecept system. Each patient received two PC transfusions: one PIPC transfusion and one control one. Posttransfusion platelet increments one hour and one day after PC transfusion, the course of hemorrhagic syndrome, and the time to next platelet transfusion were analyzed/RESULTS: Pathogen inactivation with amotosalen and ultraviolet irradiation reduced posttransfusion platelet increments in recipients by 24% after one hour and by 29% after one day after PIPC transfusion versus control ones/CONCLUSION: The clinical efficiency of transfusions of amotosalen-induced PIPC was comparable with that of untreated platelet concentrates. Despite a reduction in post-transfusion platelet increment with the use of PIPC, this caused no significant increase in the frequency of transfusions.
Terapevticheskii arkhiv. 2013;85(8):77-80
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Prognostic value of a number of blood laboratory parameters in the use of erythropoiesis-stimulating agents in anemic patients with lymphoproliferative diseases
Romanenko N.A., Bessmel'tsev S.S., Berkos M.V., Rozanova O.E., Abdulkadyrov K.M.
Abstract
AIM: To clarify the prognostic value of the baseline blood levels of endogenous erythropoietin (EE) and tumor necrosis factor-α (TNF-α) involved in the key components of the pathogenesis of anemia in lymphoproliferative diseases (LPD), the counts of reticulocytes and platelets (hematopoietic preservation indicators) in the use of erythropoiesis-stimulating agents (ESAs) to correct anemia syndrome (AS) in patients with LPD/MATERIAL AND METHODS: The results of AS treatment with ESAs were analyzed in 48 patients with LPD. A study group comprised patients with chronic lymphocytic leukemia (n=13), indolent lymphomas (n=14), and multiple myeloma (n=21). Their hemograms (hemoglobin concentration, red blood cells, packed cell volume, reticulocytes, and platelets) and blood EE and TNF-α levels were examined before using ESAs. The hemogram was monitored during treatment. ESAs (eralfon (epoietin alpha) in 21 patients and epres in 27) were subcutaneously injected in a dose of 150 IU/kg thrice weekly (for not more than 16 weeks). A control group included 21 anemic patients with multiple myeloma who did not receive ESAs. Increasing hemoglobin concentrations up to 120 g/l was regarded as a positive response to ESA treatment/RESULTS: By and large, the efficacy of epoietin alpha was 62.5% (61.9% for eralfon and 63.0% for epres), which was significantly higher than that in the control group (23.4%; p<0.05). A number of blood laboratory parameters were found to be of value in predicting the efficacy of ESAs. The patients with the decreased baseline concentrations of EE (<130 mIU/ml) and TNF-α (<15 pg/ml) were ascertained to show a positive response more frequently (80 and 92.9%, respectively; p<0.05) than those with the elevated concentrations of the enzymes in question. In addition, a positive response was more often recorded in patients with reticulocyte counts of more than 1% (77.4%; p<0.05) and platelets of 100·109/l (70%; p=0.05)/CONCLUSION: Estimating the baseline blood levels of EE and TNF-α and the counts of reticulocytes and platelets prior to the use of ESAs enables prediction of the efficiency of erythropoiesis-stimulating therapy in anemic patients with LPD.
Terapevticheskii arkhiv. 2013;85(8):81-86
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Neyromidin in the treatment of Stage I hypertensive dyscirculatory encephalopathy
Maksimova M.I., Okhtova F., Sineva N.A., Vodop'ianov N.P.
Abstract
AIM: To evaluate the efficacy and safety of neyromidin in the treatment of Stage I hypertensive dyscirculatory encephalopathy (HDE) and to analyze long-term treatment results/MATERIAL AND METHODS: Fifty-seven with Stage I dyscirculatory encephalopathy in the presence of grades 1-2 arterial hypertension were examined. Clinical, psychological, and electrophysiological studies were performed and the efficacy of neyromidin was evaluated using the SANDOS geriatric scale. Neyromidin as monotherapy was used as one tablet (20 mg) b.i.d. during a meal. The duration of course treatment was 3 months/RESULTS: Positive changes in the early manifestations of HDE were observed just on day 45 of therapy. The therapeutic effect of the drug manifested as a reduction in the degree of clinical symptoms. There were positive changes in attention, memory, kinetics, verbal associations, counting. The most noticeable improvement was seen in the values of memory and intellectual processes, suggesting higher working capacity, reduced fatigability, and eliminated sluggishness of intellectual processes. EEG displayed a higher amplitude level, a better response to rhythmic photostimulation, and a total power rise in α- and ϑ-ranges, which was indicative of the activated effect of neyromidin on the functional state of brain structures/CONCLUSION: Neyromidin (20 mg b.i.d. for 3 months) was shown to be effective and well tolerated. The drug reduced the magnitude of clinical manifestations and improved psychological functions and electrophysiological parameters.
Terapevticheskii arkhiv. 2013;85(8):87-90
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The combined drug ascoril in the treatment of patients with chronic obstructive pulmonary disease concurrent with coronary heart disease
Grigor'eva N.I., Kuznetsov A.N., Koroleva T.V., Koroleva M.E.
Abstract
AIM: To evaluate the clinical efficacy of the combined drug ascoril (Glenmark, India) in patients with grade I-II chronic obstructive pulmonary disease (COPD) concurrent with coronary heart disease (CHD)/MATERIAL AND METHODS: Sixty patients, including 12 (20%) women and 48 (80%) men, aged 43 to 68 years (mean age 55.1±9.9 years), with COPD were examined. The patients were divided into 2 groups. Group 1 used the combined broncholytic and expectorant drug ascoril and Group 2 took mucolytic agent ambroxol. The follow-up period was 7 days/RESULTS: On day 2 of ascoril treatment, all the patients showed a significant reduction in the intensity of cough that was completely relieved in 26 (87%) patients by treatment day 7. Prior to ascoril treatment, heart rate (HR) was 64.4±5.5 beats/min. A significant increase in HR to 72.7±10.1 beats/min was observed 20 min after the first drug intake (p < 0.05) and a decrease to 68.6±10.5 beats/min was seen after 60 min. On treatment day 7, HR was 63.0±6.5 beats/min, which was similar to that before ascoril treatment (p = 0.6)/CONCLUSION: In the patients with COPD concurrent with CHD, the combined drug ascoril exerts broncholytic and expectorant effects, with no pronounced negative action on HR.
Terapevticheskii arkhiv. 2013;85(8):91-94
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Irritable bowel syndrome: The present view of the problem
Maev I.V., Cheremushkin S.V., Sutugina E.A., Cheremushkina N.V.
Abstract
The paper gives an update on irritable bowel syndrome and reveals problems in its classification, pathogenesis, clinical picture, and differential diagnosis. It presents principles in the treatment of patients in the context of evidence-based medicine and proposes a treatment algorithm for the major types of irritable bowel syndrome.
Terapevticheskii arkhiv. 2013;85(8):95-100
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Moscow therapeutic schools (from the 1920s to the 1940s)
Borodulin V.I., Topolianskiĭ A.V.
Abstract
Six leading Moscow therapeutic schools in the 1920s to the 1940s are first identified and given in this paper; their personal composition, distinctive characteristics, and role in the history of Russian internal medicine are shown.
Terapevticheskii arkhiv. 2013;85(8):101-104
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