Vol 86, No 11 (2014)

Editorial
Let sleeping dogs lie ..., but bail out your friend
Pokrovskiĭ V.V.
Abstract
In 2013, 80,000 new cases of infection caused by human immunodeficiency virus (HIV) (HIV infection) were registered in Russia; there have been a total of as many as 850,000 notified HIV-infected cases in this country, which suggests that the HIV/AIDS epidemic becomes generalized. Of them, 150,000 people have died, most (22,000) cases in 2013, predominantly due to the late diagnosis of HIV infection and its delayed treatment initiation. The rise of new cases denotes that counteraction against the spread of HIV is inadequately effective; in this connection a further increase in morbidity and mortality rates should be forthcoming. However, the medical community has proved to be poorly trained to fight the epidemic; there is a lower awareness and knowledge about HIV infection among healthcare workers. To overcome the epidemic and its imminent negative implications, it is necessary to improve an epidemiological surveillance system, to introduce proven effective methods for the prevention of the disease, to increase patient access to current treatments, which will require not only higher direct expenditures on preventive measures, the creation of an infrastructure, and the purchase of medicaments and diagnostic agents, but also on the training and retraining of a large number of healthcare workers.
Terapevticheskii arkhiv. 2014;86(11):4-11
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Primary immunodeficiencies are a topical problem of modern medicine
Troitskaia E.V., Sofronova L.V., Tsvetkova T.I.
Abstract
AIM. To analyze the incidence of primary immunodeficiencies (PIDs), to reveal the specific features of the course of this condition at the present stage, and to estimate the quality of health care to patients with PIDs. MATERIALS AND METHODS. An open-label prospective trial was performed in 94 patients with different forms of PIDs (63 with selective immunoglobulin A (IgA) deficiency and 31 with other more severe primary immunodeficiencies) who had been permanent residents in the Perm Territory in the period 1990 to 2012. RESULTS. The registered PID cases were noted to be lower than the estimated ones. Over 22 years of follow-ups, the death rates for this group of patients with these diseases were 11%, and the disability rates were 27%. In severe PIDs (exclusive of selective IgA deficiency), these rates were as high as 35.5 and 96%, respectively. The rate of untimely diagnosis of severe PIDs was high (43%). Molecular genetic studies were conducted in only one tenth of the patents with this disease. PID treatment generally complied with the accepted medical standards. However, all patients with X-linked agammaglobulinemia were observed to have periodic irregularities of replacement therapy with intravenous immunoglobulins, which was a cause of death in 2 patients. Adult patients with common variable immune deficiency received no adequate replacement therapy. Timely diagnosis and adequate therapy could not only preserve the life of many patients with severe PIDs (64.5% survived), but could achieve its relatively satisfactory quality. CONCLUSION. As of now, PIDs ceased to be fatal diseases. To improve the quality of health care to patients with this pathology, there is a need to increase the awareness of the diagnosis and treatment of immunodeficiencies among physicians of different specialties, to extend the application of molecular genetic techniques, including those for prenatal diagnosis, and to continuously provide patients with essential drugs.
Terapevticheskii arkhiv. 2014;86(11):12-15
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Awareness of the issues of HIV infection in the dwellers of the Central Administrative District of Moscow
Beliaeva V.V., Adigamov M.M., Sokolova E.V., Vodinskaia I.S.
Abstract
AIM. To study the awareness of HIV infection in the dwellers of the Central Administrative District of Moscow. MATERIALS AND METHODS. A continuous cross-sectional survey was made in all the citizens who applied to the V.A. Gilyarovsky Mental Hospital Three, Branch Four, for information on the day of the survey and gave their consent to participate in this survey that was performed in 4 steps; a total of 414 persons were questioned. Their knowledge and ideas were anonymously assessed using a specially developed questionnaire. After analyzing their replies, the respondents were divided into 3 groups: 1) representatives of the so-called general population; 2) draft-age youngsters; 3) health care workers. RESULTS. The draftees (34%) gave the largest number of wrong answers to the question whether human immunodeficiency virus (HIV) could be transmitted through mosquito bites (p=0.0001). Among the healthcare workers, 81% of the respondents indicated that HIV could not be transmitted through mosquito bites; the proportion of right answers among the general population was 64.3%. The statement that a condom reliably protects against HIV infection was considered to be true by 52.4% of the health care workers, 56% of the draftees, and 62.2% of the representatives of the general population. The HIV/AIDS topic was not relevant for 43.4% of the general population and 58.3% of the health care workers; 98.7% of the respondents of the general population pointed that blood should be sampled for testing for HIV antibodies to find out whether a person had HIV (AIDS); this answer was chosen by 87.5% of the surveyed health care workers. CONCLUSION. Low knowledge about HIV infection particularly among the draft-age youngsters is evidence for the insufficient efficiency of performed preventive measures among both the general population and the organized young people. Attention is drawn to the opinion of the respondent health care workers as to the reliability of using the condom to prevent HIV transmission. The findings will be kept in mind when elaborating the teaching programs.
Terapevticheskii arkhiv. 2014;86(11):16-19
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The duration of an HIV infection course and its influencing factors
Pokrovskaia A.V., Popova A.A., Ladnaia N.N., Iurin O.G.
Abstract
AIM. To study the duration of the natural course of HIV infection and to identify its influencing factors. MATERIALS AND METHODS. 938 outpatient case histories of adult HIV-positive patients registered at the dispensary and the data of 3403 AIDS patients registered in the computer base, including those on 2588 dead people, were retrospectively analyzed. Kaplan-Meier survival analysis and Cox regression model were used. Gender, age, and route of infection were regarded as potential factors influencing the natural course of HIV infection. RESULTS. In Russia before the mass use of antiretroviral therapy (ART), the median survival from infection to death in the HIV-infected was 11.8 years; that from infection to establishment of AIDS was 11.6 years; the life expectancy following its diagnosis was 1.9 months. Patient age was a main factor influencing the course of HIV infection: in persons who had been infected with HIV at an age of over 35 years, lower CD4 lymphocyte counts and clinical progression occurred more rapidly than in those infected at a younger age. Less than 50% of the patients needed ART 5 years after HIV infection. CONCLUSION. An HIV-infected patient without ART survives almost twice less. It is necessary to detect HIV infection as early as possible and to regularly follow up patients regardless of the duration of infection in order to timely initiate its treatment.
Terapevticheskii arkhiv. 2014;86(11):20-23
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Location of foci in cerebral toxoplasmosis in HIV-infected patients
Ermak T.N., Peregudova A.B.
Abstract
AIM. To analyze the data of magnetic resonance imaging (MRI) of the brain in its toxoplasmosis in HIV-infected patients. Subject and methods. The clinical picture of cerebral toxoplasmosis was studied in 207 patients aged 18-76 years with Stage 4B HIV infection concurrent with the disease. Brain MRI using an Obraz-1 low-field (0.12 T) MRI scanner (Russia) was carried out in 115 (55.5%) patients. This investigation was conducted in 74 (65%) treated patients over time. RESULTS. Brain T2-weighted and FLAR MRI scans most frequently revealed higher-signal polymorphic foci and T1-weighted MRI scans showed lower-signal ones predominantly involving the white matter or white-grey matter border. Perifocal edema was often recorded. Intravenous gadolinium contrast study indicated that these foci accumulated the contrast agent around the periphery following the target patterns. Sixty-four (86.5%) patients were observed to have significant positive changes: reductions in the number and sizes of foci and the area of perifocal edema; in 29 patients, the inflammatory foci changed into cysts as a favorable outcome of necrotizing encephalitis. The foci resolved completely only in 7% of the patients. CONCLUSION. MRI is of great importance in intensive care, neurology, or neurosurgery units where patients with cerebral toxoplasmosis mimicking an acute cerebrovascular accident or a brain tumor are particularly frequently admitted to.
Terapevticheskii arkhiv. 2014;86(11):24-28
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Results of a comparative study of the efficacy of once daily darunavir/atazanavir in treatment-naïve patients with HIV infection
Moshkovich G.F., Minaeva S.V.
Abstract
AIM. To evaluate the efficacy of boosted darunavir and atazanavir used in antiretroviral therapy (ARVT) regimens for treatment-naïve HIV-infected patients with low baseline immune parameters and a high viral load. MATERIALS AND METHODS. The investigators evaluated the clinical, immunological, and virological efficiency of treatment: the time course of changes in CD4+ lymphocyte levels and viral load at the beginning and at 12, 24, 48, 72, and 96 weeks of antiviral therapy, as well as adverse reactions. RESULTS. The virological effect of once daily darunavir/ritonavir 800/100 mg was highly competitive with that of atazanavir/ritonavir: at 96 weeks of treatment, HIV RNA <120 copies/ml was achieved in 95% of the patients in both treatment groups. A combination of once daily darunavir/ritonavir 800/100 mg ensured a more marked immunological improvement: a difference in the increment (77.1 in 1 µl) of CD4+ lymphocyte count in patients who took darunavir (362.2 in µl) and in those who used atazanavir (285.1 in µl). In the patients who received darunavir, diarrhea, nausea, and headache were observed at the same frequency as in those who had atazanavir. CONCLUSION. The use of the test agents used in the ARVT has shown their efficacy and good tolerability.
Terapevticheskii arkhiv. 2014;86(11):29-33
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The efficacy and safety of a therapy regimen including raltegravir and a fixed dose combination of lamivudine and abacavir in previously rifabutin-treated patients with tuberculosis and HIV infection
Kravchenko A.V., Zimina V.N., Popova A.A., Deulina M.O., Kanestri V.G., Ivanova É.S., Iakovlev A.A., Pokrovskiĭ V.V.
Abstract
AIM. To evaluate the efficiency and safety of using raltegravir (RAL) twice daily in conjunction with a once-daily fixed dose combination of abacavir (ABC)/lamivudine (3TC) in patients with HIV infection and active tuberculosis who have not previously received antiretroviral therapy (ART) and have taken rifabutin as antituberculosis therapy (ATT). MATERIALS AND METHODS. The efficiency of ART was evaluated in 28 patients from a change in HIV RNA levels and from an increase in CD4+ lymphocyte counts during 48-week treatment that had been completed by 15 (53.6%) patients. The main reason for therapy discontinuation was that the patients returned to the use psychoactive agents. RESULTS. After 24 and 48 weeks of ART, the level of HIV RNA reached the undetectable values (less than 50 copies/ml) in 81.25 and 75% of the patients, respectively (according to an analysis including the patients who had completed the study in conformity with the requirements of the protocol). In only 2 patients, the virological therapy proved to be ineffective, which was likely to be associated with noncompliance with drug therapy. Following 24- and 48-week therapy, the increase in median CD4+ lymphocyte counts was 70 and 208.5 per µl, respectively. The concurrent use of ART and ATT caused positive changes in the lung skiagraphic pattern in 92.9% of the patients and complete resolution of lung tissue infiltration in 71.4%. Mixed infection ended in a fatal outcome caused by a progressive tuberculous process in 3 (10.7%) patients, in 2 of them within the first 8 weeks of treatment. The concomitant use of ATT including rifabutin and an ART (RAL + ABC/3TC) regimen was safe since one patient was noted to have a RAL-related adverse event (AE) (an allergic reaction) and caused the patient to discontinue therapy. ATT was not discontinued because of AE in any case. CONCLUSION. The ART regimen containing RAL and a fixed dose combination of ABC/3TC for adult patients with tuberculosis concurrent with HIV infection who are on combined therapy using rifabutin for tuberculosis may be recommended for the treatment of this category of patients.
Terapevticheskii arkhiv. 2014;86(11):34-41
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Tuberculosis in patients with lymphoproliferative diseases
Al'-Radi L.S., Moiseeva T.N., Chernova N.G., Sharkunov N.N., Margolin O.V., Shitareva I.V., Bariakh E.A., Kliasova G.A., Roshchina L.S., Kostina I.É., Kravchenko S.K., Pivnik A.V., Vorob'ev A.I.
Abstract
AIM. To study the clinical manifestations, diagnosis, and treatment of lymphoproliferative diseases (LPD) concurrent with tuberculosis. MATERIALS AND METHODS. In 1990 to 2013, the Hematology Research Center, Ministry of Health of Russia, followed up 4422 patients with LPD. Lymphomas and leukemias were diagnosed using the universally protocols. Tuberculosis was verified by the results of a comprehensive examination involving the histological study of biopsy specimens. RESULTS. Tuberculosis was identified in 85 (2%) patients with LPD. According to the nosological entity, the tuberculosis detection rates were 3% (40/1350) in Hodgkin lymphoma (HL), 1.2% (20/1627) in aggressive lymphomas, 1.4% (16/1136) in mature cell lymphomas and chronic lymphocytic leukemia, and 2.9% (9/309) in hairy cell leukemia. In accordance with its site, pulmonary tuberculosis was 73%; extrapulmonary tuberculosis, 14%; generalized tuberculosis, 12%. In pulmonary tuberculosis, its disseminated and focal involvements were found in 71 and 18% of cases, respectively. Tuberculosis was detected in 43% of the patients with HL in remission; it occurred only in other hemoblastoses in its active phase. When tuberculosis and LPD were simultaneously found, both diseases were concurrently treated. If the chemotherapy of LPD was effective, tuberculosis was cured in all the patients. CONCLUSION. Patients with LPD are a group at increased risk for tuberculosis. The diаgnosis of recurrent LPD must be histologically proven. When tuberculosis and LPD are simultaneously found, both diseases should be concurrently treated.
Terapevticheskii arkhiv. 2014;86(11):42-49
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The clinical and hemostasiological features of chronic hepatitides of different genesis
Bilalova A.R., Makashova V.V., Astrina O.S., Aleshina N.I., Florianu A.I.
Abstract
AIM. To comparatively characterize clinical, biochemical, and hemostasiological parameters in patients with chronic alcoholic hepatitis (CAH) and chronic mixed hepatitis (CMH), i.e. CAH + chronic hepatitis C. MATERIALS AND METHODS. Sixty-three patients (mean age 39.05±4.95 years) with chronic hepatitides of different etiology, who underwent general clinical, biochemical, and hemostasiological studies, were examined. RESULTS. The frequency and duration of major clinical symptoms were maximally pronounced in the patients with CMH. Aspartate aminotransferase concentrations were significantly decreased only in the patients with CAH, remaining at higher levels in CMH. The activity of γ-glutamyl transpeptidase was twice higher in CAH. In the patients of both groups, the total concentration of nitrates and nitrites was recorded within the normal range and the activity of von Willebrand factor was significantly higher than normal. The aggregation of platelets and erythrocytes in the patients of all the groups was significantly lower than that in the healthy individuals, but differed at different disease stages. CONCLUSION. CMH was ascertained to have a more severe course. The hemostatic system did not significantly depend on the etiology of hepatitis, but was variable in different periods of various hepatitides.
Terapevticheskii arkhiv. 2014;86(11):50-54
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Adenovirus pneumonia with a fatal outcome in adults
Iatsyshina S.B., Samchuk V.V., Vasil'ev V.V., Ageeva M.R., Vorob'eva N.S., Savochkina I.A., Bulanenko V.P., Shipulin G.A., Maleev V.V.
Abstract
AIM. To retrospectively analyze the medical records of patients who have died from complications of community-acquired pneumonia (CAP) caused by adenovirus serotype 7. MATERIALS AND METHODS. CAP was diagnosed in patients (6 men aged 19-24 years and 1 woman aged 49 years) on the basis of clinical, laboratory, and radiological findings. Adenoviral pneumonia was established by real-time polymerase chain reaction (PCR). Adenovirus DNA was detected in the patients' autopsy samples (lungs, brain, spleen, liver, blood). The adenoviruses were referred to as B1 serotype 7 on the basis of hexone gene sequencing RESULTS. Other potential causative agents of pneumonia were excluded by a battery of molecular genetic tests for a wide range of viral and bacterial pathogens of acute respiratory tract infections. RESULTS. In all cases, the disease began acutely with fever (37.8 to 39 °C), weakness, headache, a sore throat, a dry, unproductive cough or runny nose. Clinical deterioration during symptomatic therapy led to hospital admission for CAP on disease days 2-11. The patients continued to feel worse during massive antibiotic therapy, by switching a drug one to six times and by simultaneously using 2-4 antibiotics and intensive therapy. Death occurred on disease days 10-24. Postmortem examination of all the patients revealed acute respiratory distress syndrome and multiple organ failure. CONCLUSION. Adenovirus pneumonia causes diagnostic and therapeutic problems for clinicians. The clinical introduction of PCR methods for the diagnosis of viral infections allow the clinicians to elaborate and timely use effective management tactics in patients with adenoviral pneumonia and to prevent their death. It is necessary to design etiotropic therapy agents and to introduce the specific prevention of adenovirus infection in risk groups.
Terapevticheskii arkhiv. 2014;86(11):55-59
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Pneumocystis pneumonia in patients with Hodgkin lymphoma
Moiseeva T.N., Al'-Radi L.S., Sharkunov N.N., Chernova N.G., Kliasova G.A., Gracheva A.N., Bariakh E.A., Mar'in D.S., Shitareva I.V., Dzhulakian U.L., Kostina I.É., Sinitsina M.N., Galstian G.M., Kravchenko S.K.
Abstract
AIM. To assess the results of diagnosing and treating Pneumocystis pneumonia (PP) in patients with Hodgkin lymphoma (HL) over 15 years. MATERIALS AND METHODS. In 1999 to 2013, PP occurred in 22 (3%) of 741 HL patients receiving programmed polychemotherapy (PCT). The male/female ratio was 1:1.1; median age was 32 (18-65) years. Advanced stages (IIB-IV) of the disease were seen in 82% of the patients. The diagnosis of PP was established when Pneumocystis (more than 5 cysts in the specimen) was detected in the lavage fluid by indirect immunofluorescence assay. RESULTS. PP developed after 4 or more cycles of PCT. Along with Pneumocystis, all the cases were found to have additional pathogens: herpes virus in 72% and bacteria and fungi in 33%. All the patients received combined antimicrobial therapy using high doses of intravenous trimethoprim-sulfamethoxazole. Ten (45%) patients required mechanical ventilation (MV). The total mortality in PP was 32% (7 patients died); moreover, none of the patients without MV died whereas the mortality among those who had MV was 70% (7 of the 10 patients died). High death rates (80%) were noted among the patients with recurrent and resistant HL. CONCLUSION. PP should be prevented with trimethoprim-sulfamethoxazole in patients with LH during PCT. If respiratory failure and X-ray signs of interstitial pneumonia appear, there is a need for fibrobronchoscopy with bronchoalveolar lavage and comprehensive microbiological testing of lavage fluid.
Terapevticheskii arkhiv. 2014;86(11):60-65
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Evaluation of the efficiency of diagnostic regimens for enterohemorrhagic escherichiasis. Etiological verification of hemolytic uremic syndrome in the Russian Federation
Podkolzin A.T., Konovalova T.A., Veselova O.A.
Abstract
AIM. To evaluate the practical efficiency of the diagnostic algorithms for enterohemorrhagic escherichiasis, which are laid down by the current normative documents of the Russian Federation. MATERIALS AND METHODS. The investigators estimated the prevalence of enterohemorrhagic Escherichia coli (EHEC) infection in children with the symptoms of acute enteric infections (AEI) (archival samples) and in those aged less than 5 years with fatal evolution and a history of diarrhea and hemolytic uremic syndrome (HUS), evaluated the efficiency of bacteriological tests in HUS patients with acute EHEC infection, and comparatively analyzed the documents regulating EHEC surveillance in the Russian Federation and other countries. RESULTS. Nucleic acid amplification assay showed that the prevalence of EHEC among the hospitalized children was 1.2% (27/1269), the anamnestic registration rate for HUS among the children with fatal outcomes in AEI was 20% (5/25). The efficiency of the bacteriological diagnosis of enterohemorrhagic escherichiasis in the archival samples corresponding to the early stages of the disease in the presence of diarrhea and at the HUS development stage was 48.1% (13/27) and 6.1% (2/33), respectively. There was a potential to enhance the efficiency of the normative documents regulating the etiological diagnosis of EHEC infection in the Russian Federation. CONCLUSION. The given data substantiate the necessity of including the etiological diagnosis of EHEC infection in the list of mandatory screening studies in children with sporadic cases of hemocolitis at the early stages of the disease.
Terapevticheskii arkhiv. 2014;86(11):66-69
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Some features of primary facial erysipelas under the present conditions
Fokina E.G.
Abstract
Aim: to establish the features of clinical and laboratory changes in facial erysipelas in relation to its form. MATERIALS AND METHODS. Twenty-three patients (15 women and 8 men) aged 31 to 78 years who were diagnosed with moderate facial erysipelas, primary facial erysipelas being present in 91% of cases were examined. The investigators studied the biochemical substrates and enzymes and composition of proteins in the serum by an electrophoretic method, the aggregation activity of red blood cells and platelets, plasma hemostasis (a coagulogram, levels of fibrinogen, antithrombin III, and D-dimer), and von Willebrand factor, a marker of vessel wall injury, on hospital admission at disease onset (days 1-3), over time (days 4-6, 7-9), and in convalescence (days 10-12), by obligatorily using control materials. CONCLUSION. Bleeding disorders in facial erysipelas correspond to the vasculite purpuric type of hemorrhagic diathesis (according to the classification developed by Z.S. Barkagan) with the laboratory signs of evolving disseminated intravascular coagulation: impairments in erythrocyte hemostasis and blood vessel endothelium. The changes in the functional properties of red blood cells match with the suppression of metabolic processes. And if the neuraminidase effect of Β-hemolytic streptococcus is shown at the level of the red blood cell membrane, the activity of NADase blocks processes in the entire macroenergetics. In the presence of a high fever reaction, the low levels of transaminases (aspartate aminotransferase, alanine aminotransferase) and membrane enzymes (alkaline phosphatase, creatinine phosphokinase) decrease the detoxification capacities of serum and increase a load on blood albumin and erythrocyte barriers. Rapid normalization of C-reactive protein levels enables one to use this simple and highly sensitive test to monitor the involution of erysipelatous inflammation and the efficiency of treatment. The changes in the hemostatic system and metabolic tests are less pronounced in patients with facial erysipelas than in those with lower-extremity erysipelas.
Terapevticheskii arkhiv. 2014;86(11):70-77
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Clinical features of pertussis in adults
Popova O.P., Petrova M.S., Borisova O.I., Skirda T.S., Gracheva N.M., Malyshev N.A.
Abstract
AIM. To study the clinical features of pertussis in adults. MATERIALS AND METHODS. The clinical manifestations of pertussis in adults were analyzed in 62 patients treated in the Core Unit and Obstetric Unit, Clinical Infectious Diseases Hospital One, Moscow Healthcare Department, in 2011-2013. RESULTS. Investigations conducted in the familial foci of pertussis showed that its incidence rate was 23.7 and 10% in adults and in pediatric institutions, respectively. The source of infant infection was adults in almost one third of cases, mothers in 72% and fathers in 27.7%. Assessment of the symptom complex of pertussis in the sick mothers in the observed period ascertained that 94±3% had experienced the typical form of whooping cough: 72.0±5.7 and 22.0±5.3% had its mild and moderate forms, respectively. The disease had run a latent course in 6±3% of the patients. The paper describes cases of pertussis in 5 pregnant women admitted to the obstetric unit for complaints of persistent cough. The diagnosis of whooping cough in all the cases was based on clinical and epidemiological findings and serological tests showing specific IgA and IgG antibodies. Three and two patients experienced moderate and mild pertussis, respectively. CONCLUSION. Pertussis now remains one of the infectious diseases relevant not only to a pediatric population, but also to an adult one. Adult pertussis maintains the main clinical features typical for this infection with a predominance of its mild forms, which makes its diagnosis difficult. A serological test (enzyme immunoassay) is of high diagnostic value for verifying whooping cough in adults under the present conditions.
Terapevticheskii arkhiv. 2014;86(11):78-81
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South African tick bite fever in a group of Russian tourists
Kozhevnikova G.M., Tokmalaev A.K., Voznesenskiĭ S.L., Karan' L.S.
Abstract
The paper describes a clinical case of South African tick bite fever in a group of Russian tourists. The group of 5 people who had been ill with this disease after a tourist trip to the South African Republic (the Kruger National Park in the north-eastern province of Mpumalanga) were followed up. During their trip, all of them were bitten by different insects many times. The disease exhibited different clinical presentations; however, all the patients were noted to have a fever with slight intoxication and a maculopapular rash at different sites of the body; 3 had lymphadenopathy and one had a primary effect at the site of tick sticking. The diagnosis was verified by indirect immunofluorescence for the detection of high titers to Rickettsia сonorii. The course of the disease was favorable in all the patients treated with antibiotics (doxycycline or ceftriaxone).
Terapevticheskii arkhiv. 2014;86(11):82-83
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A case of acute opisthorchiasis concurrent with chronic hereditary hemolytic anemia
Navrotskiĭ A.N.
Abstract
The paper analyzes the clinical and laboratory manifestations of acute Opisthorchis invasion concurrent with chronic hereditary hemolytic anemia before and after antihelminthic therapy. It gives the results of direct clinical observation of a patient in the acute phase of opisthorchiasis in the presence of Minkowsky-Shauffard disease. His examination encompassed conventional laboratory and instrumental studies used in hepatology, such as physical, biochemical, and immunological examinations (tests for viral hepatitis markers and autoimmune liver diseases), and abdominal ultrasound scanning and magnetic resonance imaging. The patient with acute opisthorchiasis concurrent with hemolytic anemia was found to have a preponderance of clinical and laboratory manifestations of hepatocholangitis in the early stages of the disease and a prevalence of subfebrility with progressive eosinophilia in the presence of regressive symptoms. The clinical and laboratory signs of hereditary microspherocytosis suggest that the process is decompensated. The found clinical and laboratory changes correspond to the natural course of the diseases. The magnitude of changes in laboratory parameters suggests that there is an intercurrent interaction of infectious and somatic diseases, but does not hinder dehelminthization.
Terapevticheskii arkhiv. 2014;86(11):84-85
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Pulmonary vasculitis as a clinical mask of HCV infection: Efficiency of interferon-free antiviral therapy
Stel'makh V.V., Kozlov V.K., Sukhanov D.S., Skipskiĭ I.M.
Abstract
The paper describes a clinical case of pulmonary vasculitis caused by hepatitis C virus (HCV). Its diagnosis was established on the basis of in-depth laboratory testing and an investigation of the molecular biological markers of viremia (polymerase chain reaction - PCR - HCV RNA) in peripheral blood mononuclear cells. By taking into account of extrahepatic HCV replication and contraindications to interferon therapy, the female patient was given an interferon-free antiviral therapy cycle using an interferonogenic inductor in combination with ribavirin. Pathogenic therapy (methylpred and ursodeoxycholic acid) was additionally performed. An interferon-free regimen of cycloferon + ribavirin led to sustained remission of HCV infection running with its systemic manifestations. The therapy could improve the function of not only the liver, but also the lung. In suspected extrahepatic HCV infections, an investigation of molecular biological markers for viremia (HCV RNA PCR) in the peripheral blood mononuclear cells is an essential diagnostic technique. Interferonogenic inductors, cycloferon in particular, should be used in combination with ribavirin when a chronic hepatitis C patient with the extrahepatic manifestations of HCV infection has contraindications to conventional therapy with recombinant interferon-α.
Terapevticheskii arkhiv. 2014;86(11):87-92
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Herpes zoster-induced neuralgia (neuropathy)
Maksimova M.I., Sineva N.A., Vodop'ianov N.P.
Abstract
Neuralgia (neuropathy) is the most common manifestation of herpes zoster (HZ). In spinal and cranial neuralgia, there are 3 types of pain: 1) spontaneous, persistent, burning pain; 2) intermittent sharp pain; 3) pain occurring with nonpainful stimulation. The skin exhibits areas of hypesthesia, anesthesia, and dysesthesia. Ophthalmic neuralgia (of the first branch of the trigeminal nerve) is encountered in 20% of HZ cases. HZ of the auricle and external auditory meatus concurrent with facial and vestibulocochlear neuropathy is diagnosed as Ramsay Hunt syndrome. Postherpetic neuralgia (neuropathy) is characterized by pain present for 3 months or more after the appearance of herpetic eruptions. Combined therapy involving the earlier use of antiviral agents, tricyclic antidepressants, analgesics, and neuromidine is the most effective option for HZ-induced neuralgia (neuropathy).
Terapevticheskii arkhiv. 2014;86(11):93-99
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Entecavir in the treatment of chronic hepatitis B: multicenter randomized trials and real clinical practice
Abdurakhmanov D.T., Otrashevskaia A.V.
Abstract
The goal of treatment for chronic hepatitis B (CHB) is now to improve quality of life and to prevent the poor outcomes of the disease rather than to eliminate the virus from the body. This goal may be achieved via the long-term maintenance of aviremia. According to the International and Russian clinical guidelines, entecavir is the first-line drug of choice to treat patients with CHB. For almost 10 years of world clinical practice there has been evidence that entecavir has a high efficacy and a favorable safety profile in a number of randomized clinical trials and in real medical practice worldwide, in Russia in particular. For instance, the BRAVR (Baraclude Russian Analysis of Virological Response) trial of 147 CHB patients from 10 Russian cities indicated that the rate of aviremia was 85.8% (n=147), 89.9% (n=138), 89.4% (n=97), and 93.5% (n=81) at 1, 2, 3, and 4 years, respectively. In addition to its virological, immunological, and biochemical efficacies, entecavir also proved to be effective in achieving the regression of histological changes and in preventing the decompensation of cirrhosis and the development of carcinoma. The given data permit the use of entecavir for the long-term therapy of CHB with confidence.
Terapevticheskii arkhiv. 2014;86(11):100-104
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Simeprevir in combination with pegylated interferon-α and ribavirin in the treatment of naïve patients with genotype 1 chronic hepatitis C
Burnevich É.Z.
Abstract
Triple therapy with pegylated interferon-α, ribavirin, and simeprevir is now optimal among the antiviral treatment options available in the Russian Federation for patients with chronic hepatitis C (CHC), including in the compensated stage of liver cirrhosis. The optimality of this combination is determined by its high efficacy - the given combination of antiviral agents allows one to predict that more than 90% of naïve patients with CHC will achieve a sustained virological response as 97-99% of the Russian population patients is infected with hepatitis C virus subgenotype 1b. The second important aspect that can recognize the triple therapy incorporating simeprevir to be most rational now is its safety similar to that of double therapy with pegylated interferon-α and ribavirin. In addition, the absolute advantages of the triple therapy including simeprevir are shorter treatment duration (for a total of 24 weeks) for all naïve patients with CHC, including those in the compensated stage of cirrhosis, and simeprevir taken as one capsule once daily.
Terapevticheskii arkhiv. 2014;86(11):105-114
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Acute respiratory distress syndrome: How to optimize oxygen transport and to improve prognosis
Shtabnitskiĭ V.A., Chuchalin A.G.
Abstract
The paper reviews the state-of-the-art of acute respiratory distress syndrome (ARDS) and current approaches to correcting respiratory failure. It highlights the historical and present-day data on the efficiency of extracorporeal membrane hemoxygenation, high-frequency ventilation, surfactant and inhaled nitric oxide therapy, and prone ventilation. The examinations have shown that ventilation in the prone position and extracorporeal membrane hemoxygenation not only improve gas exchange, but have a positive prognostic impact. The use of inhaled nitric oxide and surfactant achieves improved oxygenation for a while, but has no substantial effect on prognosis. The place of high-frequency oscillatory ventilation in the treatment of patients with ARDS has not been fully determined as some examinations have indicated a positive prognostic impact and other examinations have shown none or a negative impact.
Terapevticheskii arkhiv. 2014;86(11):115-122
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Use of nonsteroidal anti-inflammatory drugs in case of ankylosing spondylitis: Long and persistently!
Karateev A.E., Érdes S.F.
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are extensively used in the treatment of rheumatic diseases to relieve pain and signs of inflammation. However, when treated for ankylosing spondylosis (AS), NSAIDS exert both symptomatic and structure-modifying effects, by slowing down the development of vertebral ankylosis. The effect of these drugs, which underlines the formation of syndesmophytes, may be associated with their anti-inflammatory activity and ability to suppress abnormal bone proliferation. There is convincing evidence to support the capacity of NSAIDs, when long and continuously used, to reduce the rates of X-ray progression of AS. So the continuous use of NSAIDs must be now considered to be a mandatory component of pharmacotherapy for this disease. Their use should be continued even after achieving a marked clinical improvement. At the same time, this situation requires that the development of adverse reactions as structural and functional diseases of the gastrointestinal tract and cardiovascular system be thoroughly controlled in this situation. The danger of these complications determines the need for a physician's attention, obligatory consideration of risk factors, and rational choice of the safest NSAIDs.
Terapevticheskii arkhiv. 2014;86(11):123-127
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Cognitive impairments as a universal clinical syndrome in a therapist's practice
Shishkova V.N.
Abstract
The problem of cognitive dysfunctions in patients with somatic diseases occupies a prominent place now since they are one of the most common manifestations of organic brain lesions. The early detection of potentially cured cognitive impairments is one of the important tasks of a present-day therapist, cardiologist, endocrinologist, and family doctor as the patients with early-stage cognitive impairments constitute the majority of those who have sought medical advice. In the modern world, primary health care physicians' actions are decisive in predicting the development of dementia since the detection of early non-dementia forms of cognitive impairments and neuroprotective therapy with mexidol in particular are frequently quite sufficient to considerably reduce the degree of the impairments and to improve the prognosis of dementia.
Terapevticheskii arkhiv. 2014;86(11):128-134
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Detection of cognitive deficit in a therapist's practice: Review of screening scales
Kutlubaev M.A.
Abstract
Acute and chronic cognitive impairments quite often complicate visceral diseases. In this connection, it is important for a therapist to know brief scales to screen for cognitive impairments. Tests, such as a six-component screener, a short orientation-memory-concentration test, a short portable mental status questionnaire, Hodkinson's abbreviated mental test (AMT) (AMT-4 and AMT-10), a clock drawing test, and 4 'A's Test (4AT) may be used for the primary assessment of cognitive functions. Mini-Mental Status Examination may be further used if dementia is suspected; the Montreal Cognitive Assessment may be applied to identify moderate cognitive impairments. Special scales, such as the confusion assessment method for the intensive care unit, are employed to diagnose acute cognitive dysfunction.
Terapevticheskii arkhiv. 2014;86(11):135-138
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