Vol 85, No 11 (2013)

Editorial
The relevance and prospects of introducing a uniform federal register of patients with viral hepatitis B and C in Russia
Pimenov N.N., Vdovin A.V., Komarova S.V., Mamonova N.A., Chulanov V.P., Pokrovskiĭ V.I.
Abstract
The article provides the current epidemiological characteristics of viral hepatitis B and C and the existing problems of registering parenteral viral hepatitides in Russia. It justifies the need for introducing a uniform federal registry of patients with viral hepatitis B and C and shows prospects for its introduction
Terapevticheskii arkhiv. 2013;85(11):4-9
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The HIV infection situation in the Russian Federation
Sokolova E.V., Pokrovskiĭ V.V., Ladnaia N.N.
Abstract
AIM: To evaluate current trends in the development of an epidemic process of HIV infection in Russia. Materials and methods. Case report forms entering the Federal Research Methodology Center for AIDS Prevention and Control of the Central Research Institute of Epidemiology, Russian Inspectorate for the Protection of Consumer Rights and Human Welfare, were analyzed/RESULTS: In Russia, the HIV epidemic is on the rise; both the absolute number of people with HIV infection and its rate in the population are increasing. Compared with 2000, there is a shift of the epidemic to older age groups (30-40 years); there are increases in the proportion of women among new HIV-infected cases and in the number of babies born to HIV-positive mothers. Injection drug use remains a major risk factor for HIV transmission; the number of people infected through heterosexual intercourse continues to rise every year/CONCLUSION: The main reason for a more widespread HIV epidemic is the very low coverage of both vulnerable groups and the general population with prevention programs.
Terapevticheskii arkhiv. 2013;85(11):10-15
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Experience with Invirase as part of triple therapy as the drug of choice in the perinatal prevention of HIV transmission in the Ulyanovsk Region
Salminskaia O.I.
Abstract
AIM: To retrospectively analyze the efficacy and safety of ritonavir-boosted saquinavir (SQV) in the perinatal prevention of HIV infection in pregnant women in the Ulyanovsk Region. Materials and methods. The outpatient cards of HIV-positive pregnant women who received ritonavir-boosted SQV in a dose of 1000/100 mg bid in combination with zidovudine or stavudine and lamivudine for the perinatal prevention of HIV infection in 2010-2011 were retrospectively analyzed. The main efficiency criterion was a proportion of children taken off a regular medical check-up in terms of perinatal contact as healthy at 18 months post-birth. The additional criteria (end points) were changes in viral load and CD4 cell count at 4 and 8-12 weeks after initiation of prevention/RESULTS: The analysis included data on 98 HIV-positive pregnant women. The history of HIV infection was 3 years or less in 63.2% of the patients. Stage 3 and 4A HIV infection was stated in 87 and 13% of the women, respectively. Treatment with ritonavir-boosted SQV + 2 nucleotide reverse transcriptase inhibitors was started in 84.8% of the women at 15-28 weeks' gestation and in 12.2% of cases in earlier periods. Four weeks after initiation of highly active antiretroviral therapy, the viral load showed a 1-4 log10 decrease. By that time and at 8-12 weeks, it was undetectable (<500 copies/ml) in 75 (76.5%) and 82 (83.6%) women, respectively. With a decrease in the viral load, CD4 cell count increased by 100-500 per mm3 (mean 160 per mm3). The efficiency of prevention of perinatal HIV transmission was 100%. No serious adverse events were observed/CONCLUSION: The use of ritonavir-boosted SQV in combination with two nucleotide reverse transcriptase inhibitors is an effective and safe chemoprevention regimen for perinatal HIV transmission in pregnant women.
Terapevticheskii arkhiv. 2013;85(11):16-20
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The application of Decision Trees for constructing an algorithm for the differential diagnosis of zoonotic infections
Platonov A.E., Sarksian D.S., Maleev V.V.
Abstract
AIM: To attempt to construct an algorithm using the routine epidemiological, clinical and laboratory data for the differential diagnosis of ixodid tick-borne borreliosis (ITBB) caused by Borrelia miyamotoi (BM-ITBB) and other zoonotic infections that are endemic in Russia/MATERIAL AND METHODS: The investigation enrolled the adult patients treated at the Republican Hospital for Infectious Diseases (Izhevsk) in 2010-2012 with diagnoses of BM-ITBB (n=71), Lyme disease (n=38), tick-borne encephalitis (TBE) (n=25), and hemorrhagic fever with renal syndrome (n=27). The Decision Tree procedure in IBM SPSS Statistics was used to analyze more than 65 variables characterizing a disease case/RESULTS: The final decision tree had 7 dichotomous fissions in accordance with the values of several indices (presence of erythema migrans, tick bite, goat's milk consumption, sweating, vertigo, nausea, abdominal pain, as well as blood concentrations of platelets, alanine aminotransferase, and count, and urea) and formed 8 terminal nodes. The proposed algorithm provides correct classification in 95% of disease cases/CONCLUSION: ITBB caused by B. miyamotoi can be successfully discriminated from other widespread zoonotic infections. Thus, practitioners have an additional opportunity to detect and diagnose the "new" infection BM-ITBB.
Terapevticheskii arkhiv. 2013;85(11):21-26
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Current principles in the chemoprophylaxis of acute respiratory viral infections
Shul'diakov A.A., Liapina E.P., Kuznetsov V.I.
Abstract
AIM: To evaluate the preventive efficacy of the Russian antiviral drug ingavirin (vitaglutam) in the epidemiological foci with the peak incidence of acute respiratory viral infections (ARVI)/MATERIAL AND METHODS: Four hundred men and women aged 18 to 65 years from the epidemic foci of ARVI who had been in close daily contact with the patients whose diagnosis was verified by laboratory tests were examined. Two hundred persons received prophylaxis with ingavirin (a 90-mg oral capsule once daily for 7 days) and 200 took placebo according to the same scheme. The efficiency index and coefficient were calculated and the relative risk of the disease was estimated to evaluate the efficiency of ARVI prevention. A pharmacoeconomic analysis was made/RESULTS: There is evidence that the administration of 90-mg ingavirin capsules (OAO "Valenta Farm", Russia) caused a reduction in morbidity rates among those who had been in contact by 63% and in the risk of ARVI by 2.7 times. There was a reduction in the duration of fever by one day and a milder course of respiratory disease in the ingavirin-treated contact persons who developed ARVI/CONCLUSION: Ingavirin meets all requirements for current drugs for the nonspecific prevention of ARVI at the peak of its incidence. It has a pronounced protective effect and broad-spectrum activity, low toxicity and high safety, which allows it to be recommended for the emergency intrafocal prevention at the peak of the incidence of influenza and ARVI in adults.
Terapevticheskii arkhiv. 2013;85(11):27-33
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C-reactive protein as a marker of the severity of an infectious process in acute myeloid leukemia patients with neutropenia
Vladimirova S.G., Tarasova L.N., Skol'skaia O.I., Cherepanova V.V.
Abstract
AIM: To determine C-reactive protein (CRP) levels as diagnostic markers of infection in acute myeloid leukemia (AML) patients with neutropenia/MATERIAL AND METHODS: Sixty-three AML patients (28 men and 35 women) aged 20 to 77 years (median 50 years) were examined. According to the French-American-British (FAB) classification, the types of AML were as follows: M0 (n=3), M1 (n=9), M2 (n=35), M4 (n=10), and M5 (n=6). All the patients had chemotherapy-associated neutropenia (granulocytes, less than 0.5·109/l). In different treatment steps, all the patients developed infectious complications (the study analyzed the data of 86 cases)/RESULTS: In patients with localized infections (such as mucositis, abscess, pneumonia, etc.) or fever of unknown origin (FUO), the levels of CRP were not statistically significant different, but were significantly higher than in those without infectious complications. The concentrations of CRP did not differ in patients with systemic inflammatory response syndrome (SIRS) and in those with sepsis. At the same time, the level of CRP in systemic infection (SIRS, sepsis) was significantly higher than that in localized infection (p<0.001). In patients with neutropenia, the median CRP levels were as follows: 7 mg/l (range 0-37; 95% reference interval (RI) 0 to 32) for those without infection 56 mg/l (range 13-104; 95% RI 17 to 104) for those with localized infection or FUO; and 168 mg/l (range 103-399; 95% RI 105 to 362) for those with systemic infection/CONCLUSION: CRP is a marker of the severity of an infectious process in AML patients with neutropenia. The increase of its level more than 32 mg/l serves a valid criterion for the presence of infection and more than 105 mg/l does for that of a systemic inflammatory response in these patients.
Terapevticheskii arkhiv. 2013;85(11):34-40
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Cryptococcosis in hematology practice
Khodunova E.E., Frolova I.N., Parovichnikova E.N., Kravchenko S.K., Galstian G.M., Kostina I.É., Mikhaĭlova E.A., Gracheva A.N., Kliasov G.A.
Abstract
AIM: To study the clinical manifestations of cryptococcosis, its diagnostic features, and treatment results in patients with hemoblastoses/MATERIAL AND METHODS: The study included adult patients with cryptococcosis treated at the Hematology Research Center (HRC) in 2005 to 2011. The diagnosis of cryptococcosis was established on the basis of isolation of Cryptococcus neoformans from a blood culture or determination of positive cryptococcal antigen in the cerebrospinal fluid (CSF) of patients with infection symptoms/RESULTS: During 7 years, 19 patients aged 19 to 68 years (median 47 years) were diagnosed as having cryptococcosis. In the pattern of cryptococcosis, there was a preponderance of patients with lymphoma (31%) and those with acute lymphoblastic leukemia (26%) at the stages of hemoblastosis remission induction (32%) and consolidation (26%). The diagnosis was made in 9 (47%) patients at the Intensive Care Department, HRC. The major risk factors of cryptococcosis were previous cytostatic drug exposure (68%), use of immunosuppressive and glucocorticoid drugs (63%), and granulocytopenia (42%). Seventeen (78%) patients were diagnosed with cryptococcal meningitis or meningoencephalitis; 1 patient had cryptococcal sepsis and 1 patient had possible cryptococcal pneumonia. All the patients were given antifungal agents. Amphotericin B, fluconazole, and a combination of antimycotics were used as first-line drugs in 16 (84%), 1 (5.5%), and 2 (10.5%), respectively. When their health became better, the patients were treated with voriconazole or fluconazole. Within 30 days after the diagnosis of cryptococcosis, 5 (26%) patients died; of them 2 had tumor progression concurrent with infection/CONCLUSION: In cryptococcosis, the central nervous system is predominantly involved in the infectious process. The determination of cryptococcal antigen in CSF is a necessary diagnostic component in meningitis and meningoencephalitis in patients with blood system tumors, lymphatic ones in particular. When cryptococcosis is timely diagnosed and treated, its mortality, when the tumor is controlled, is lower than that in other invasive mycoses.
Terapevticheskii arkhiv. 2013;85(11):41-46
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Results of treatment for candidemia in patients with blood system tumors
Kliasova G.A., Blokhina E.V., Gracheva A.N., Kravchenko S.K., Parovichnikova E.N., Galstian G.M.
Abstract
AIM: To study the etiology, clinical manifestations, risk factors, and results of treatment for candidemia (CE) in patients with blood system tumors/MATERIAL AND METHODS: The investigation included the patients with CE and hemoblastoses treated at the Hematology Research Center, Ministry of Health of the Russian Federation, in 2006 to 2012. The diagnosis of CE was established according to the single isolation of Candida spp. from blood cultures and the presence of infection symptoms/RESULTS: Over 7 years, CE was diagnosed in 57 patients aged 17 to 77 years (median age 48 years). Among the patients with CE, there was a preponderance of those with lymphomas (54%) and acute leukemias (30%). The pathogens of CE were C. albicans (33%), C. guilliermondii (26%), С. parapsilosis (12%), С. krusei (8%), C. lusitaniae (5%), С. famata (4%), C. tropicalis (4%), С. glabrata (4%), and C. pelliculosa (4%). The major risk factors were polychemotherapy (85%), granulocytopenia (63%), mucosal Candida spp. colonization (82%), the presence of central venous catheter (CVC) (97%), antibiotics (100%), and glucocorticosteroids (70%). The infection occurred with the intake of an antifungal agent in 33% of the patients; 60% had concomitant infections of other etiology. Antifungal agents were given to 52 (91%) patients. Within 30 days after CE diagnosis, 20 (35%) patients died; of them 12 (60%) patients showed tumor progression concurrent with the infection. The cure rate for CE was significantly higher in the use of echinocandin as a first-line drug (92%), in complete or partial remission in hemoblastosis (90%), CVC removal (76%) and in the administration of an antifungal drug on day 1 of detection of positive blood cultures (75%). The cure rate was significantly lower when septic shock developed and a patient was transferred to an intensive care unit (15%), when amphotericin B was used as a first-line drug (45%), when granulocytopenia occurred (53%), or glucocorticoids were given (55%)/CONCLUSION: Candida non-albicans constitute a high proportion among the pathogens of CE. A number of risk factors influencing survival rates in CE have been identified. It is crucial to use echinocandin as a first-line agent as soon as possible after isolation of Candida spp. from blood cultures.
Terapevticheskii arkhiv. 2013;85(11):47-53
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The value of changes in CD8+CD28+ and CD4+CD28+ cells in patients with HIV infection concurrent with tuberculosis during treatment
Popova A.A., Kravchenko A.V., Kozhevnikova G.M., Zimina V.N.
Abstract
AIM: To study the proportion of CD8+CD28+ and CD4+CD28+ cells among the CD8+ and CD4+ lymphocytes and the changes in these indicators in patients with HIV infection/tuberculosis (HIV/TB) versus those with HIV infection and those with TB/MATERIAL AND METHODS: One hundred and six persons were examined and included into 4 study groups: 1) 39 patients with concomitant HIV/TB; 2) 25 patients with HIV monoinfection without TB who had not previously received antiretroviral therapy; 3) 17 patients with TB without HIV infection; 4) 25 healthy individuals (a control group)/RESULTS: CD28 expression was found to be much more reduced on the CD8 lymphocytes than that on the CD4 ones. This is likely to be due to earlier CD8 lymphocyte dysfunction in both the patients with HIV infection and those with HIV/TB although the CD4 cell is the basic virus target/CONCLUSION: The study of the proportion of CD8+CD28+ cells among the CD8 lymphocytes is of more informative value than the determination of that of CD4+CD28+ among the CD4 lymphocytes.
Terapevticheskii arkhiv. 2013;85(11):54-57
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Use of infusion solution remaxol in the combination treatment of patients with leptospirosis
Lebedev V.V., Zhuravlev A.I., Zotov S.V., Lebedev P.V., Pronin M.G., Podsadniaia A.A., Arbuzova E.K., Svistunov N.V.
Abstract
AIM: To evaluate the efficiency of using remaxol in the combination treatment of patients with leptospirosis/MATERIAL AND METHODS: Thirty patients (29 men and 1 woman) with leptospirosis were treated with remaxol. The icteric and anicteric forms of the disease were diagnosed in 28 and 2 patients, respectively. Moderate, severe, and very severe leptospirosis were observed in 3, 24, and 3 cases, respectively. Remaxol was injected intravenously as a ready-to-use infusion solution 400 ml/day; the treatment duration was 3 to 9 days at the height of the disease/RESULTS: Clinical improvement and normalization of laboratory parameters were achieved in the course of the disease. There were no deaths. During early convalescence at 4-5 weeks of the disease, the patients taking remaxol at the height of the disease were substantially more rarely recorded to have general weakness, fever, anorexia, myalgia, leukocytosis, increased erythrocyte sedimentation rate, and hyperbilirubinemia than those untreated with this drug/CONCLUSION: The performed study established the clinical efficacy of remaxol when used in the combination treatment of patients with leptospirosis.
Terapevticheskii arkhiv. 2013;85(11):58-61
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Human babesiasis
Malov V.A., Tokmalaev A.K., Erovichenkov A.A., Tsvetkova N.A., Sadykova V.D., Smetanina S.V., Nemilostiva E.A., Bogdanova M.V.
Abstract
The paper describes a case of imported babesiasis caused by Babesia microti. This is an account of the second case of babesiasis in the Russian-language medical literature. Its clinical picture and laboratory data in the course of the disease are depicted and analyzed. Its clinical differential diagnosis with malaria and an update on the diagnosis and treatment of babesiasis are discussed.
Terapevticheskii arkhiv. 2013;85(11):62-66
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Pneumocystis pneumonia and generalized tuberculosis in HIV-infected patients
Mikhaĭlova N.R., Ermak T.N., Mikhaĭlovskiĭ A.M.
Abstract
The paper describes a clinical case of pneumocystis pneumonia in the presence of generalized tuberculosis in a female patient with HIV infection. The lack of prevention of pneumocystosis and its late diagnosis and treatment resulted in a fatal outcome. The problem of early clinical diagnosis in the concurrent course of secondary involvements is discussed.
Terapevticheskii arkhiv. 2013;85(11):67-68
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The course of parvovirus B19 infection during pregnancy after kidney transplantation
Mavrina E.S., Garmaeva T.T., Troitskaia V.V., Makhinia S.A., Glinshchikova O.A., Biriukova L.S., Mikhaĭlova E.A., Parovichnikova E.N., Savchenko V.G.
Abstract
Having a tropism for erythroid progenitor cells, parvovirus B19 may cause partial red cell aplasia and thrombocytopenia. Early diagnosis of parvovirus B19 infection in immunocompromised patients is needed for timely antiviral therapy. A high-risk group for parvovirus B19 infection includes patients with blood diseases who receive multiple transfusions of blood components; those who have undergone donor organ transplantation and are long taking immunosuppressive drugs; and pregnant women. These patients require careful virological monitoring for major blood-borne viral infections. This paper describes a clinical case of parvovirus B19 infection in a pregnant woman who has undergone kidney transplantation and is continuously taking immunosuppressive medications. Identification of the cause of severe anemia and timely adequate therapy could lead to the recovery of effective erythropoiesis in the patient.
Terapevticheskii arkhiv. 2013;85(11):69-72
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Clinical epidemiology: Theory and practice
Polibin R.V., Briko N.I., Mindlina A.I.
Abstract
The paper gives the definition, goal, and objectives of clinical epidemiology. The latter is shown to be an epidemiology section that makes it possible to elaborate evidence-based standards for diagnosis, treatment, and prevention and to select a respective algorithm of actions for each specific clinical case. Randomized controlled trials are the gold standard for obtaining evidence. Scales are proposed to evaluate the efficacy of preventive and therapeutic agents: the levels of evidence for their efficacy and the level of strength of its evidence. The authors propose to set up clinical epidemiology centers, one of whose goals should be to introduce a unified system to evaluate the efficacy of preventive and therapeutic agents, by using the principles of evidence-based medicine and the methods of clinical epidemiology.
Terapevticheskii arkhiv. 2013;85(11):73-74
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Vascular stiffness and diastolic heart failure
Drapkina O.M., Kaburova A.N.
Abstract
Vascular stiffness is regarded as a result of degenerative processes potentiated by aging, hypertension, and other risk factors. Central hemodynamic changes are one of the serious sequels of high arterial stiffness, which gives rise to a chain of events as a higher postload on the left ventricle, its concentric hypertrophy, diastolic dysfunction and increases the overall risk of cardiovascular events. The purpose of the review is to discuss the mechanisms of vascular stiffness, focusing on the role of this condition in the development of chronic heart failure with retained ejection fraction and its pathogenetic treatment as a future target.
Terapevticheskii arkhiv. 2013;85(11):75-81
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Sepsis: a new look at the problem
Beloborodova N.V.
Abstract
The recent proceedings of congresses and forums on sepsis were used to write this review. The available definitions of sepsis and ideas on its etiology and pathogenesis are critically analyzed. There is information on new concepts of sepsis and data on a search for new targets, diagnostic and therapeutic approaches, and biomarkers. It is hypothesized that there is a mechanism of action of bacteria on mitochondrial dysfunction and human hormonal regulation with low-molecular weight exometabolites, namely aromatic microbial metabolites.
Terapevticheskii arkhiv. 2013;85(11):82-90
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Triple therapy for chronic hepatitis C: Practical Aspects
Bakulin I.G., Kiseleva A.V.
Abstract
The paper considers the practical aspects of antiviral therapy with protease inhibitors, a new group of antiviral agents, by using the clinical cases of treatment in patients with chronic hepatitis C as an example. It gives the general points of triple therapy, including indications for its use in previously untreated and unresponsive patients, and discusses in detail possible adverse events and ways of their prevention and correction.
Terapevticheskii arkhiv. 2013;85(11):91-99
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Immunotherapy for infectious diseases: challenges and prospects
Karaulov A.V., Kaliuzhin O.V.
Abstract
The fact that many infectious diseases are not effectively controlled with etiotropic drugs determines the relevance of a search for alternative methods, particularly those based on the modulation of immunity. The review analyzes rational approaches to the immunotherapy of infectious diseases, such as regulation of acquired immunity; correction of the quantitative and qualitative composition of the intestinal microbiota; and modulation of innate immunity. Among the drugs affecting the innate components of an immune response, the derivatives of muramyl dipeptide (MDP), a structural subunit of bacterial cell wall peptidoglycan, stand out in the context of a detailed study of the cellular and molecular mechanisms of action. The fact that it is expedient to clinically apply these immunomodulators in many diseases accompanied by inadequate infection control is beyond question. It is demonstrated that muramyl peptides (MP) may be also used to prevent excessive inflammatory responses. The adjuvant properties of MDP and its analogues can be employed for therapeutic vaccination. The data that the signals transmitted through NOD-like receptors (MP sensors) regulate intestinal homeostasis suggest that there is some potential for the use of MDP derivatives for the correction of dysbiosis and related immune disorders. Whatever the purpose of immunomodulation, the key to its effectiveness is to personalize the choice and regimens of immunotropic drugs.
Terapevticheskii arkhiv. 2013;85(11):100-108
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Use of darunavir in HIV-infected women during pregnancy
Afonina L.I., Voronin E.E.
Abstract
The use of antiretroviral drugs (ARVDs) in a mother and a child can reduce the risk of vertical transmission of human immunodeficiency virus (HIV) to less than 1%; therefore, highly active antiretroviral therapy is used in all pregnant women regardless of indications for HIV-infection treatment. The major requirements for choosing an ARVD to prevent mother-to-child HIV transmission are its high safety for a pregnant woman, a fetus, and a baby and its high therapeutic efficacy. Clinical trials of darunavir (DRV) in adults and children have shown a high virologic response, good tolerance, and safety. Trials and observations have demonstrated the high efficacy and safety of a DRV when used in pregnant women. Pharmacokinetic studies in pregnant women have indicated the effective and well-tolerated concentration of a DRV when it is co-administered with low-dose ritonavir, which permits the use of a DRV for both the prevention of mother-to-child HIV transmission and the treatment of pregnant women who require antiretroviral therapy. The Russian clinical protocol "Use of ARVDs in the package of measures for the prevention of mother-to-child HIV transmission" approved by the National Scientific Society of Infectiologists in 2013 recommends DRV as an alternative drug in antiretroviral therapy regimens for pregnant women to prevent mother-to-child HIV transmission and to treat maternal HIV infection.
Terapevticheskii arkhiv. 2013;85(11):109-114
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Dengue fever in Russian tourists who have come from Thailand
Shestakova I.V., Iushchuk N.D., Akinfiev I.B., Popova T.I., Sergeeva T.V., Vdovina E.T.
Abstract
The review analyzes the major epidemiological and clinical aspects of Dengue fever, by providing the clinical examples of using its imported cases. It gives algorithms for examining patients who have come from tropical countries with the fever of unknown origin. Based on the extensive data available in the literature and international guidelines, the authors present treatment algorithms for out- and inpatients with Dengue fever. Promising studies of vaccination against Dengue fever are analyzed.
Terapevticheskii arkhiv. 2013;85(11):115-124
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Use of maraviroc, the first CCR5 receptor antagonist, in HIV treatment regimens
Kravchenko A.V.
Abstract
The paper gives the results of international trials of and guidelines for the use of maraviroc, the first CCR5 receptor antagonist, in treatment regimens for HIV-infected patients. The trials have convincingly shown that the maraviroc-containing antiretroviral therapy (ART) regimens are highly effective and safe for R5-tropic HIV-infected patients regardless of previous ART, baseline HIV RNA levels, and CD4+ lymphocyte count. Maraviroc can be recommended for HIV-infected patients who have previously received ART and who have been found to have a R5-tropic virus. The changes in the ART regimen and inclusion of maraviroc may be associated with both an ineffective previous treatment regimen and therapy-induced adverse events. In 2012, Russia's first reagent kit for the determination of HIV tropism was put to tests and registered at the Russian Inspectorate for the Protection of Consumer Rights and Human Welfare.
Terapevticheskii arkhiv. 2013;85(11):125-129
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The review gives data on the clinical manifestations, complications, and epidemiological characteristics of herpes zoster.
Afonina N.M., Mikheeva I.V.
Abstract
It discusses prospects for and foreign experience with vaccination against chickenpox and exacerbations of herpes zoster. The clinical and epidemic characteristics of shingles (herpes zoster) and its prevention with vaccines
Terapevticheskii arkhiv. 2013;85(11):130-133
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