Vol 87, No 4 (2015)


Better diagnosis is an obligatory condition for improving medical care quality

Glybochko P.V., Mukhin N.A., Svistunov A.A., Fomin V.V.


The paper discusses current approaches to organizing a diagnostic process in health care facilities. It describes approaches to improving patient examinations in multidisciplinary hospitals.
Terapevticheskii arkhiv. 2015;87(4):4-7
pages 4-7 views

Assessment of the role of matrix metalloproteinase-2 gene polymorphism in the development of chronic heart failure

Teplyakov A.T., Berezikova E.N., Shilov S.N., Grakova E.V., Torim Y.Y., Efremov A.V., Safronov I.D., Pustovetova M.G., Karpov R.S.


Aim. To study the impact of a polymorphic variant of the matrix metalloproteinase-3 (MMP-3) gene on the development and course of chronic heart failure (CHF) in patients with coronary heart disease. Subjects and methods. A total of 277 patients with New York Heart Association (NYHA) Functional Class (FC) II—IV CHF were examined. MMP-3 –1171 5A/6A genetic polymorphism was studied by polymerase chain reaction. A control group included 136 patients (mean age 53.6±4.8 years) with no signs of cardiovascular diseases, as evidenced by the examination. Results. The frequency of the 5A allele and the 5A/5A genotype of the 1171 5A/6A polymorphic locus in the MMP-3 gene proved to be higher in the patients with CHF than that in the control group. Thus, the variability of the 5A allele (odds ratio (OR), 1.39; 95% confidence interval (CI): 1.033 to 1.869; p=0.03) and the 5A/5A genotype (OR, 2.15; 95% CI: 1.131 to 4.070; p=0.02) was associated with increased risk for CHF. There were significant differences in the frequency of MMP-3 alleles and genotypes in relation to FC of CHF. The frequency of the 5A/5A genotype was substantially higher in the patients with NYHA FC IV CHF than that in those with NYHA FC II CHF (32.8% versus 15.2%; р=0.039). The frequency of the 5A allele was significantly higher in the patients with NYHA FC IV CHF than that in those with NYHA FC II CHF (55.5% and 39.3%; respectively; р=0.019). Thus, the carriage of the 5A allele and the 5A/5A genotype of the 1171 5A/6A polymorphic locus in the MMP-3 gene is a risk factor of severe CHF. Conclusion. The determination of ММР-3 –1171 5A/6A polymorphism may be recommended for the early prediction of a risk for the development and severe course of CHF.
Terapevticheskii arkhiv. 2015;87(4):8-12
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Gender-related features of risk factors for, and age- and gender-related differences in the severity and genesis of chronic heart failure

Bakhshaliev A.B., Dadashova G.M., Bakhshalieva G.I.


Aim. To analyze the gender-related features of the prevalence of chronic heart failure (CHF) in Azerbaijan and to estimate the detection rate and risk factors of this condition in inpatients on the basis of a retrospective follow-up study. Materials and methods. A total of 1824 case histories of CHF patients admitted with a CHF diagnosis to the Azerbaijan Research Institute of Cardiology in 2013 were analyzed. Results. The prevalence of CHF is 51.4% among the patients admitted to the Azerbaijan Research Institute of Cardiology. The major etiological factors of CHF are ischemic heart disease (IHD) and hypertension in 79.9% of the. There are gender-related differences in the pattern of cardiovascular diseases in the patients with CHF: IHD (prior myocardial infarction) and hypertension are more common in men and women, respectively. The incidence of CHF was 56.8% among the men; it was registered in them 1.3-fold more often than in the women; 41% of the patients with CHF were older than 60 years. CHF with a left ventricular ejection fraction of <45% was diagnosed in 84% of the patients. Among the patients with CHF and preserved left ventricular ejection fraction, the number of women rose up to 22%, which was twice higher than that for the men. Conclusion. Substantial differences were found in the etiology of CHF in men and women, as well as in patients of different ages.
Terapevticheskii arkhiv. 2015;87(4):13-18
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Prognostic value of risk factors for cardiovascular diseases and target organ damages for the occurrence of resistant hypertension

Lazutkina A.Y., Gorbunov V.V.


Aim. To estimate the prognostic value of risk factors for cardiovascular events and target organ damages for the occurrence of resistant hypertension (RH). Subjects and methods. The 2008—2013 survey covered 7959 members of locomotive crews of the Transbaikal Railway whose medical expert examination revealed risk factors for cardiovascular diseases and target organ damages. Results. During the survey, a group of 7959 people with final outcomes included 21 RH cases to be statistically analyzed. Atherosclerotic plaques in the carotids arteries, proteinuria, creatininemia, overweight, left ventricular hypertrophy, a family history of early cardiovascular diseases, and stress were the major predictors of RH. Conclusion. The association of the established predictors must be considered in the treatment of patients with RH.
Terapevticheskii arkhiv. 2015;87(4):19-23
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Cerebrovascular reactivity in patients with rheumatoid arthritis concurrent with and without hypertension

Rebrova N.V., Anisimova E.A., Sarkisova O.L., Mordovin V.F., Karpov R.S., Ripp T.M., Trifonova T.G., Bogomolova I.I.


Aim. To compare cerebrovascular reactivity (CVR) in patients with rheumatoid arthritis (RA) concurrent with essential hypertension (Group 1) and in those with RA and normal blood pressure (BP) (Group 2). Subjects and methods. During the study of Groups 1 (n=37) and 2 (n=12), the investigators estimated the prevalence of traditional cardiovascular risk factors, performed 24-hour BP monitoring, investigated CVR by transcranial Doppler (TCD) of the middle cerebral arteries (MCA) by hyperoxic and hypercapnic tests, and endothelium-dependent vasodilation (EDV) and endothelium-independent vasodilation of the brachial artery. The groups were matched for gender, age, RA activity and stage, and antirheumatic therapy volume. Results. According to the results of MCA TCD, the hyperoxic test recorded impaired CVR in 34 (92%) and 10 (83%) patients in Group 1 and 2, respectively; the hypercapnic test revealed this condition in 19 (51%) and 6 (50%) patients in these groups, respectively. The hyperoxic test most commonly showed an insufficient decrease in MCA linear blood flow velocities (LBFV) in 31 (84%) and 8 (66%) patients in Groups 1 and 2, respectively; the hypercapnic test did an excessive increase in MCA LBFV in 12 (32%) and 4 (33%) patients, respectively. There was a high rate of impaired EDV in 32 (86%) and 9 (75%) patients in Groups 1 and 2, respectively. Conclusion. According to the results of MCA TCD, there were high and similar rates of impaired CVR in patients with RA concurrent with and without essential hypertension during the hyperoxic and hypercapnic tests.
Terapevticheskii arkhiv. 2015;87(4):24-29
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Specific features of hypertension in patients with systemic lupus erythematosus

Savina Z.E., Shilkina N.P.


Aim. To study the specific features of the development and course of hypertension in patients with systemic lupus erythematosus (SLE). Subjects and methods. A total of 106 age- and sex-matched patients, including 47 with SLE and 55 with hypertensive disease (HD), were examined. In all the patients, plasma renin levels were determined; serum von Willebrand factor antigen concentrations were estimated; desquamated endothelial cell counts were calculated; and 24-hour blood pressure (BP) monitoring (BPM) and Doppler ultrasound of carotid arteries performed. Results. In the patients with SLE and hypertension compared to those with HD, the mean diastolic BP (DBP) was 86.5 (79.5—93.5) mm Hg versus 80.5 (77—90) mm Hg (daytime) and 78 (69—91.5) mm Hg versus 72.5 (64—78) mm Hg (nighttime) (p<0.05), and there was also a decrease in daily DBP index (5 [0.5—15]% versus 11 [7.5—18]% (p<0.02)). The plasma renin levels were 1.67 (0.78—2.47) and 0.49 (0.25—0.81) ng/ml/h in the patients with SLE and in those with HD, respectively, р=0.04 and 0.42 (0.36—0.47) ng/ml/h in the control group (р=0.0001). An atherosclerotic vascular lesion was found in 52 and 32% of the patients with SLE and those with HD, respectively. The von Willebrand factor antigen levels were 1.63 (0.81—3.36) and 0.29 (0.23—2.8) IU/ml in these patients, respectively (p=0.04). The plasma circulating endothelial cell counts were also significantly higher in the patients with SLE and hypertension than in those with HD (8 [7—10]∙104/l and 5 [3—8]∙104/l (p<0.01). Conclusion. The patients with SLE and hypertension show a high rate of its hyper-renin states, a propensity for nocturnal hypertension, an increase in DBP, and obvious vascular endothelial regulatory dysfunction.
Terapevticheskii arkhiv. 2015;87(4):30-35
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Clinical and pathogenetic features of esophageal spasm

Firsova L.D., Pichugina I.M., Yanova O.B., Berezina O.I., Bordin D.S.


Aim. To comparatively analyze clinical manifestations in patients with primary esophageal spasm (ES) and its concurrence with gastroesophageal reflux disease (GERD) and the results of their instrumental examinations and psychodiagnostic tests. Subjects and methods. A total of 104 patients with the clinical and manometric signs of ES were examined and divided into two groups: 1) 42 patients with primary ES; 2) 62 patients with ES concurrent with GERD. The examination encompassed esophageal manometry, esophagogastroduodenoscopy, 24-hour pH metry, and an interview using a questionnaire to identify autonomic disorders, and the Mini-Mult test. Results. The patients with primary ES compared to those with ES concurrent with GERD significantly more frequently showed severe pain syndrome (p=0.009) and a paradoxical dysphagia pattern (p=0.03); manometry revealed an incoordination in the motility of the entire esophagus (p=0.001). Comparison of the statistical series of values for contraction amplitude and duration in the distal esophagus found no significant difference in the patients of both groups. Autonomic disturbances were detected in 76.0% of the patients with ES; but the intergroup differences were insignificant. Mental maladaptation was observed in 81.7% of the patients in the absence of intergroup differences. Conclusion. The etiopathogenetic factor of ES is a psychoautonomic response to chronic stress in both primary ES and its concurrence with GERD. The reflux of gastric contents into the esophagus does not appear to be one of the leading causes of ES. In primary ES, esophageal motor function is generally impaired to a much greater extent than that in ES concurrent with GERD. The degree of motor disorders is embodied in the specific clinical features of the disease.
Terapevticheskii arkhiv. 2015;87(4):36-40
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HIV/AIDS masks in a therapist’s practice

Roshchina A.A., Ponomareva E.Y., Rebrov A.P.


Aim. To investigate clinical manifestations and diagnostic difficulties in patients with HIV/AIDS in the practice of therapeutic units of a multidisciplinary hospital. Subjects and methods. The investigation included 65 HIV/AIDS patients admitted to the therapy units of a Saratov Regional clinical hospital in 2007 to 2011. The clinical features of HIV/AIDS, immunological status, and viral load were studied. Results. The structure of the clinical manifestation of HIV/AIDS showed a preponderance of lung injury in 45 (69%) patients. There were hematological disorders in 38 (58%) patients and nephropathy in 33 (51%); 11 (17%) patients were diagnosed with infective endocarditis. Rheumatic symptoms and syndromes mimicking HIV/AIDS were found in 10 (15.4%) patients. The degree of immune disorders was most severe in patients with pulmonary dissemination and rheumatic masks and mutually related to the rate of cutaneous manifestations. The specific features of lung injury, infective endocarditis, pulmonary hypertension, rheumatic symptoms, and kidney injury were discussed in HIV/AIDS patients having different causes for admission to specialized therapy units. Conclusion. In connection with the clinical polymorphism of HIV/AIDS, physicians of all specialties should be alert for the possible clinical manifestations of this disease to timely examine patients.
Terapevticheskii arkhiv. 2015;87(4):41-46
pages 41-46 views

Clinical features of sleep-related breathing disorders in patients with acromegaly

Tsoy U.A., Sviryaev Y.V., Korostovtseva L.S., Semenov A.P., Vaulina D.A., Nepran V.I., Kravchenko S.O., Konradi A.O., Grineva E.N.


Aim. To investigate the incidence of sleep-related breathing disorders (SRBDs) in patients with active acromegaly (AM), to specify risk factors influencing apnea/hypopnea index (AHI), and to reveal the specific features of obstructive sleep apnea (OSA) in patients with AM versus those with OSA without AM. Subjects and methods. Fifty patients with active AM were examined and divided into 3 groups: control group 1 did not differ from the study group in body mass index (BMI); control group 2 did not similar in AHI from the AM group. Polysomnography was done in all the patients. Results. SRBDs were detected in 40 (80%) patients. Obstructive apnea was found in all cases. Correlation analysis revealed the relationships between AHI and gender (AHI was higher in the men), BMI, disease duration, and insulin-like growth factor 1 (IGF-1). There were no correlations between AHI and gender, maximum adenoma size, and growth hormone levels. Compared with control group 1, the AM group had a statistically significantly higher median AHI [16 (1—92) and 4.7 (0—31.3) episodes per hour of sleep (p<0.001)]. In control group 2, the median BMI was considerably higher than in the control group [29.2 (19.9—44.3) and 35 (24—56) kg/m2 (p<0.001). Conclusion. The detection rate of SRBDs in patients with active AM was 80%, with obstructive disorders being prevalent. There was a positive relationship between SRBD severity and BMI, AM duration, IGF-1 level. Compared to the controls, the patients with AM developed SRBDs similar in severity with lower BMI; severer SRBDs were detected in the patients with active AM with the similar BMI.
Terapevticheskii arkhiv. 2015;87(4):47-52
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Dyssynergic defecation is one of the causes of chronic constipation

Karlov A.V., Orlova N.V., Parfenov A.I.


Aim. To define the rate and type distribution of dyssynergic defecation (DD) in patients with primary chronic constipation (CC) and to evaluate the efficiency of biofeedback (BFB) therapy. Subjects and methods. One hundred and thirty-two 18-to-89-year-old patients treated in the Moscow Clinical Research and Practical Center for primary CC were examined using proctological examination, colonofibroscopy, anorectal manometry (ARM), and the balloon expulsion test. Results. Different types of DD were identified in 44.69% of the patients. Defecation disorder type 1 was prevalent (in 64.4% of the patients with DD). The positive result of BFB therapy was noted in the patients with DD and fecal incontinence. Conclusion. The timely detection of functional defecation disorders can recover the lost function of pelvic floor muscles by BFB therapy and exclude the uncontrolled patient use of laxatives.
Terapevticheskii arkhiv. 2015;87(4):53-57
pages 53-57 views

Adherence with proton pump inhibitor therapy, by continuously taking nonsteroidal anti-inflammatory drugs

Pimanov S.I., Makarenko E.V., Dikareva E.A.


Aim. To estimate the impact of adherence with proton pump inhibitor (PPI) therapy on the incidence of nonsteroidal anti-inflammatory drug (NSAID)-induced gastropathy (NSAID gastropathy) in patients with rheumatoid arthritis (RA). Subjects and methods. PPI pharmacotherapy adherence was estimated using the Medication Adherence Questionnaire (MAQ) in 92 patients with RA, including 32 patients did not take a PPI and 60 used a PPI. The groups were matched for age, disease duration, and used NSAIDs. All those asked underwent video esophagogastroduodenoscopy. Results. According to the data of MAQ survey, low, moderate, and high adherence subgroups could be identified among the patients treated with a PPI. NSAID gastropathy was detected in 43.8% of the patients taking no PPI, in 50% of those with low PPI treatment adherence, in 12.5% with moderate adherence, and in 4.5% with high adherence. In the patients with low adherence to PPI therapy, NSAID gastropathy was recorded 11 times more frequently than in those with high adherence (c2=7.77; p=0.005). This condition occurred in 28.6% of the patients taking NSAID without preventively using a PPI in the absence of risk factors for NSAID gastropathy. Conclusion. Only 36.7% patients who had been recommended to use a PPI for the prevention of NSAID gastropathy strictly observed their doctor’s directions. Low PPI pharmacotherapy adherence may serve as an additional risk factor for NSAID gastropathy in patients in whom preventive antisecretory therapy used in combination with NSAID is indicated.
Terapevticheskii arkhiv. 2015;87(4):58-61
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Treatment for knee osteoarthritis in patients with oxalate nephropathy

Voronina N.V., Slutskaya N.P., Markina O.I., Kovalskaya L.P., Agievich T.B., Gelmutdinov D.D., Bushina A.V.


Aim. To elucidate the safety profile and symptom-modifying effect of Аlflutop and diacerein in the treatment of Kellgren—Lawrence Stages II—III knee osteoarthrosis (OA) in patients with oxalate nephropathy and Stages I—II chronic kidney disease (CKD) and to refine the effect of these drugs on urinary syndrome and renal function as compared to a response to nonsteroidal anti-inflammatory drugs — cyclooxygenase inhibitors (diclofenac). Subjects and methods. This open-label comparative randomized trial enrolled 86 female patients with Kellgren—Lawrence Stages II—III primary gonarthritis concurrent with oxalate nephropathy and Stages I—II CKD. The patients were randomized into 3 groups: 1) 20 patients took diclofenac sodium 100 mg/day; 2) 30 received a complex pharmaceutical on the basis of glycozaminoglycans Аlflutop injection 1 ml per day for 20 days, then 2 ml intraartricular twice weekly in the following month; 3) 36 had diacerein (diaflex, «Rompharm Company») in a dose of 50 mg twice daily for 3 months. On day 30 and day 90 of treatment, the symptom-modifying effect was evaluated from changes in the joint pain and morning stiffness domains of the WOMAC index. Renal function was measured using the estimated glomerular filtration rate (GFR), uric acid clearance (Cua), and urinary sediment. Results. On day 30 of treatment, the patients taking diclofenac were found to have nephrotoxic effects (lower GFR, Cua, evolving secondary hyperuricemia, progressive proteinuria, emerging microhematuria, elevated urinary levels of total lipid hydroperoxides, and enhanced calcium oxalate crystalluria). Alflutop and diacerein exerted no negative effects on renal function. On day 30 day of treatment, all the patient groups showed a reduction in the WOMAC pain score. The diclofenac group displayed a more marked decrease in the pain score than did the two other groups by day 30. Otherwise by day 90 of therapy with Аlflutop and diacerein, the pain scores were reduced by 60 and 67%, respectively, which was similar to those in the diclofenac group by day 30 of a follow-up. By day 30 day of treatment, the stiffness score was also observed to fall in all the groups and achieved even lower values in the Аlflutop and diacerein groups compared with diclofenac group.. Conclusion. Alflutop and diacerein used by patients with knee OA do not produce nephrotoxic effects and by day 90 demonstrated similar to diclofenac symptom-modifying effect by reducing pain and stiffness scores. Diclofenac administration contributed to oxalate nephropathy progress.
Terapevticheskii arkhiv. 2015;87(4):62-68
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Evolution of ideas on microscopic colitis

Maev I.V., Kucheryavyi Y.A., Andreev D.N., Cheremushkin S.V.


The literature review gives the present-day views of the definition, etiology, pathogenesis, diagnosis, and treatment of microscopic colitis (MC). In the present view, MC is an inflammatory bowel disease of unknown etiology, which is characterized by chronic watery diarrhea, no macroscopic signs of large bowel involvement in the presence of specific pathomorphological changes. There are two major forms of MC, which are similar in its clinical picture, yet, heterogeneous in histological criteria: collagenous colitis (CC) and lymphocytic colitis (LC). As of now, the prevalence of MC is about 100 cases per 100,000 population, which is similar with that in other inflammatory bowel diseases, such as ulcerative colitis and Crohn’s disease. MC generally prevails in women aged over 50 years. The etiology and pathogenesis of MC have not fully investigated. Watery diarrhea is as a predominant pathognomonic symptom in all the patients with MC. The major histological criterion for the diagnosis of CC is subepithelial collagen lining thickening (more than 10 µm) and that for LC is higher intraepithelial lymphocyte counts (more than 20 intraepithelial lymphocytes/100 epitheliocytes). The topical glucocorticosteroid budesonide is currently the only agent, the efficacy of which has been proven in both inducing and maintaining remission in patients with MC in many clinical trials.
Terapevticheskii arkhiv. 2015;87(4):69-76
pages 69-76 views

Ascites, spontaneous bacterial peritonitis, hepatorenal syndrome: What is common in their diagnosis and treatment?

Bakulin I.G., Varlamicheva A.A.


Complications of cirrhosis are a main cause of death in the immediate and late follow-up periods in these patients. Portal hypertension, edematous-ascitic syndrome, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic encephalopathy are poor predictors. The sociomedical importance of these complications is obvious for reasons of the high risk of death in these patients in the immediate period (15—30 days). This review represents a set of practical algorithms whose basis is the most effective methods to diagnose, treat, and prevent complications of cirrhosis.
Terapevticheskii arkhiv. 2015;87(4):77-83
pages 77-83 views

Ursodeoxycholic acid: A therapeutic niche in an internist’s practice

Drapkina O.M., Bueverova E.L.


The paper shows more than 40 years’ experience with ursodeoxycholic acid (UDCA) used as a drug; during this period it has demonstrated its rather high clinical efficacy. Due to the range of its inherent pleiotropic (choleretic, cytoprotective, immunomodulatory, antiapoptotic, hypocholesterolemic, and litholytic) properties, UDCA has a broad spectrum of therapeutic activity. The paper considers the issues associated with the mechanism of action and with the clinical effects of this bile acid. It gives the results of the most important randomized controlled trials determining currently the evidence base for the efficiency and safety of using UDCA in the clinical picture of visceral diseases.
Terapevticheskii arkhiv. 2015;87(4):84-90
pages 84-90 views

B-cell lymphoma, unclassifiable, intermediate between diffuse large B-cell lymphoma and Burkitt’s lymphoma

Baryakh E.A., Misyurina A.E., Kovrigina A.M., Misyurin V.A., Kravchenko S.K.


B-cell lymphoma that is unclassifiable and intermediate between diffuse large B-cell lymphoma (DLBCL) and Burkitt’s lymphoma (BL) — (UBL) is an aggressive lymphoma that has simultaneously morphological, immunophenotypical, and cytogenetic signs of both DLBCL and LB. At the same time due to its biological characteristics and clinical manifestations, UBL cannot be referred to as one of the above nosological entities. UBL has been first identified as an individual nosological entity in the 2008 World Health Organization classification. The review details the epidemiology, clinical manifestations, morphological pattern, immunophenotypic and karyotypic features, as well as therapeutic approaches and prognostic factors.
Terapevticheskii arkhiv. 2015;87(4):91-97
pages 91-97 views

Role of ascorbic acid and tocopherol in the prevention and treatment of diseases from the standpoint of evidence-based medicine

Shikh E.V., Makhova A.A.


The role of vitamin C and vitamin E in the prevention and treatment of diseases is analyzed from the standpoint of evidence-based medicine. The high provision of a patient with the vitamins has a therapeutic and preventive impact on the development and course of a number of diseases. Furthermore, when additionally prescribing the vitamins as part of combination therapy, it is necessary to take into account possible drug interactions, including those due to the inducing effect of the above antioxidants on cytochrome P450 3A4.
Terapevticheskii arkhiv. 2015;87(4):98-102
pages 98-102 views

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