Vol 86, No 8 (2014)

The paper presents current views on the diagnosis and medical treatment of Crohn's disease (CD). It considers the present-day principles in the classification, evaluation of the severity of the disease, and its diagnostic criteria. There are actual medical treatment regimens for CD, regulated by the project of Russian clinical guidelines for the diagnosis and treatment of CD in adults (2013), which were drawn up by leading Russian experts relying on the European evidence-based consensus on the diagnosis and management of CD (2010). Promising treatment options for CD, which affect the key molecules of the pathogenesis of this disease, are considered.

AIM. To assess the relationship of different components of metabolic syndrome (MS), viral load, and HBeAg status to the risk for cirrhosis of the liver in patients with chronic hepatitis B (CHB). MATERIALS AND METHODS. Fifty-three patients with CHB were examined according to the conventional criteria for patients with chronic hepatitis (the 2012 EASL guidelines). Analysis is made in relation to the degree of liver fibrosis (LF), the presence of MS, abdominal obesity, and insulin resistance (IR). RESULTS. MS was detected in 22.6% of the patients with CHB. The duration of the latter in MS was noted to be longer; the patients with MS were accordingly older than those without MS. The patients of this category were significantly more frequently observed to have type 2 diabetes mellitus (DM2), and IR, hepatic steatosis, and >3 METAVIR scores for LF, and elevated activity of hepatic enzymes (alanine aminotransferase, aspartate aminotransferase). Marked LF was associated with a high viral load, obesity, DM2, patient age, and MS. The patients with MS showed a higher activity of hepatic enzymes than those with abdominal obesity without MS. CONCLUSION. The percentage of CHB patients with MS increases with disease duration and patient age. High viral load, disease duration, MS, obesity, and DM2 are associated with score >3 METAVIR scores for significant LF.

AIM. To assess the role of matrix metalloproteinases (MMP) in the clinical and functional status of smoking patients with persistent asthma. MATERIALS AND METHODS. Examinations were made in 16 healthy smokers (a control group), 22 healthy nonsmoking volunteers (a volunteer group), and 16 patients with endogenous (n=6) and mixed (n=10) persistent asthma (a study group) with varying disease control. The investigators used the following techniques: spirometry; determination of airway resistance and FeCO in the expired air; 30-minute percutaneous monitoring of blood oxygenation and 6-minute walk test; enzyme immunoassay for matrix metalloproteinase levels. RESULTS. The longer duration and higher intensity of smoking increase airway inflammation in the asthmatic patients and the length of blood oxygenation within the very low range. The combined negative influence of tobacco smoking and the underlying disease leads to a clinically significant decrease in pulmonary ventilation ability and basic levels of blood oxygenation, the occurring asthma control reduction being correlating with the longer duration of treatment. The investigators revealed the predictors of lowering the mean level of blood oxygenation (MMP-9, FeCO, and airway resistance), as well as the factors that negatively influence the level of dyspnea and fatigue in asthmatic smokers. CONCLUSION. The serum levels of FeCO and MMP-9 may serve as markers reflecting the intensity of airway inflammation in smokers with persistent asthma.

AIM. To evaluate the efficiency of psychotherapeutic methods on the clinical course of gastroesophageal reflux disease (GERD), quality of life (QL), esophagogastroduodenoscopic findings and 24-hour pH monitoring readings in patients with this condition. MATERIALS AND METHODS. Sixty patients with GERD were divided into equal groups according to performed therapy: standard drug treatment or its combination with psychotherapeutic methods. The investigators estimated the degree of esophageal mucosal damage by esophagogastroduodenoscopy, esophageal acidity by 24-hour pH monitoring, and the magnitude of clinical manifestations by the Likert scale and assessed QL by the SF-36 questionnaire. The psychoemotional health component was analyzed using the clinical questionnaire for the identification and evaluation of neurotic states (CQIENS), the Leonhard-Shmichek characterological questionnaire, and the individual typological questionnaire. RESULTS. The patients with GERD were found to have individual personal traits and a definite psychological response. Incorporation of psychotherapeutic methods into the combination therapy was ascertained to have an additional therapeutic effect against the clinical manifestations of GERD, psychological responses in the patients, and QL indicators. There was a direct relationship between the psychological component of QL and the data of the CQIENS questionnaire. The most significant correlation was found between the CQIENS anxiety scores and the psychological component of QL (r=0.73; p=0.00004). Correlation analysis in the patients with GERD showed a relationship between the CQIENS anxiety scores and the clinical index (r=-0.68; p=0.0001). CONCLUSION. The use of psychotherapeutic methods in addition to standard drug therapy improves both the physical and psychological states in patients with GERD and has some impact on a reduction in the magnitude of clinical symptomatology. This may contribute to the prompter recovery of patients and create prerequisites for improving their QL.

AIM. To estimate the pharmacoeconomic parameters of treatment in patients with Helicobacter pylori-associated diseases when using 6 eradication therapy (ET) regimens. MATERIALS AND METHODS. The investigation enrolled a total of 231 patients who received anti-Helicobacter pylori therapy according to the intention-to-treat (ITT) principle, including 229 patients who met the protocol requirements, i.e. who completed the prescribed per-protocol (PP) treatment: 106 patients with duodenal bulb ulcer disease, 2 with gastric ulcer, 90 with erosive gastritis, and 31 patients with non-atrophic gastritis. In an outpatient setting, the patients received one of the 6 ET regimens: OAC, RBMA, RBCA, EBCA, sequential OACM therapy, and modified sequential OACMB therapy (O - omeprazole; A - amoxicillin; C - clarithromycin; B - bismuth tripotassium dicitrate, R - rabeprazole; M - metronidazole; E - esomeprazole). Treatment costs were calculated only from direct drug expenditures. The effective cost coefficient (Keff) was determined from the cost/treatment efficiency ratio: Keff=cos/eff, where the cost was the average total costs; the eff was efficiency (%). RESULTS. The modified sequential OACMB therapy has proven to be more cost-efficient than the other regimens as it has a lower Keff (14). The RBMA regimens can overcome an 80% ET barrier (82.4%); however, in this case the Keff is 21.5. the sequential OACM therapy can also overcome an 80% ET barrier (84.8%); the Keff being 10.8. Incorporation of the bismuth preparation can achieve a more noticeable therapeutic effect up to 95.4%. The EBCA regimen has turned out to be most expensive with the highest Keff of 36.9. The RBCA regimen is most effective with the least Keff of 29; the therapeutic effect is 96.7%. CONCLUSION. The clinical cost-efficiency of ET is enhanced by the incorporation of the bismuth preparation for the treatment of patients with H. pylori-associated diseases. The modified sequential OACMB therapy can overcome resistance to clarithromycin and metronidazole with a good cost-efficiency.

AIM. To study the possibility of using a paired (test) H-reflex recovery test in the expert assessment of the intensity of acute pain syndromes and in the control of performed therapy. MATERIALS AND METHODS. The authors analyzed 40 patients treated for radicular pain syndrome (RPS) caused by disk protrusion or herniation at the lumbar spine with the pain intensity of up to 9 points on digital rank scale of pain. As a clinical model they used a pathogenetically sound therapeutic blockade method including glucocorticosteroids for the therapy of acute neuralgia and basic medical therapy with Arcoxia 120 mg/day. Investigations were conducted to study the specific features of early recovery of test H-reflex caused in pair with a conditioning H-reflex in both healthy volunteers and patients with obvious RPS. RESULTS. There were different features of paired H-reflex recovery in healthy individuals and patients with RPS during different treatment options. Recovery of test H-reflex in the range of 150-200 msec can be a criterion for a pain state. CONCLUSION. The clinical test reflex recovery technique may be used in the diagnosis and monitoring of the performed therapy of acute pain syndromes, as well as in the expert examination of pain states.

AIM. To study the effect of metformin on metabolic parameters, body weight (BW), and waist circumference (WC) in patients with abdominal obesity (AO). MATERIALS AND METHODS. The results of using metformin 2000 mg daily for 3 months in 46 patients with АО. The comparison group consisted of 50 people. BW, WC, and blood pressure (BP) were measured; lipid profile parameters and blood insulin concentrations were determined; and Homeostasis Model Assessment (HOMA) estimates were calculated. Metabolic syndrome (MS) and AO were judged by the 2005 International Diabetes Federation (IDF) criteria. RESULTS. The study and comparison groups showed were reductions in BW by 4.2 and 1.7 kg and in WC by 4.2 and 1.1 cm, respectively. Metformin used in the patients with AO contributed to a more significant improvement in the lipid profile than in those who received no medication. A decrease in the HOMA index was observed only in the metformin group. The effects of the drug were more pronounced in MS and insulin resistance. The use of metformin in the patients with AO decreased lower BW and HOMA index and improved lipid metabolism even in the absence of MS. CONCLUSION. The trial has demonstrated that the people with AO may take metformin could be used in to reduce BW and WC and to treat and prevent MS.

AIM. To evaluate the impact of 6-month antihypertensive therapy with the combined drug amlodipine + lisinopril (ekvator) on endothelial dysfunction (ED) and carbohydrate metabolic parameters in patients with hypertension and type 2 diabetes mellitus (DM). MATERIALS AND METHODS. The investigation enrolled 30 patients aged 40-65 years with Stages II-III hypertension concurrent with type 2 DM. All the patients received combined antihypertensive therapy with amlodipine + lisinopril for 24 weeks. Endothelial function (EF) was studied from the serum and urine concentrations of the metabolites nitric oxide (NO) and endothelin-1 (ET-1) and from occlusion test RESULTS. Carbohydrate metabolic parameters were estimated. Insulin resistance (IR) was judged from basal insulin concentrations, followed by the calculations of the Homeostasis Model Assessment (HOMA) index. RESULTS. Following 24 weeks of therapy with amlodipine + lisinopril and close adherence to dietary recommendations, all the patients achieved the target levels of blood pressure and glycated hemoglobin (HbA1c). There was a significant improvement in EF in hypertensive patients with type 2 DM: NO production was increased in both the serum and urine (by 122.8 and 65.8%, respectively). ET-1 secretion was naturally decreased in both the serum and urine (by 26.1 and 76.1%, respectively; p<0.05). Analysis of the vascular component of EF during treatment with the combined drug amlodipine + lisinopril revealed a statistically significant patient redistribution by the types of microcirculation and the results of an occlusion test, by calculating the responsiveness of large arteries: the number of patients with normal microcirculation increased from 13.3 to 86.7% and that of patients with hyperemic microcirculation declined from 66.7 to 0. The number of patients with a paradoxical occlusion test significantly reduced from 46.7% at baseline to 20% after 24 weeks of treatment with the combined medication amlodipine + lisinopril. Fasting blood glucose levels and HOMA index were decreased by 22.1 and 22.4%, respectively (p<0.05). There were statistically significant correlations between the HOMA index and the concentrations of NO in the urine (r=-0.45) and blood (r=-0.54) and those of ET-1 in the blood (r=-0.54). CONCLUSION. Twenty-four-week combined antihypertensive therapy with the drug amlodipine + lisinopril is safe and highly effective in EF recovery and favorably affects carbohydrate metabolic parameters in the hypertensive patients with type 2 DM.

The problems of the timely diagnosis and treatment of primary hyperparathyroidism (PHPT) have recently attracted more and more attention because this disease now ranks third in incidence rates among endocrine diseases. Older women form a group at risk for this disease. Surgical removal of the source of parathyroid hormone hypersecretion is the only radical treatment option for this disease, which is performed in the majority of patients with PHPT. Occasionally, surgical treatment is contraindicated or unadvisable. In these cases, the possibilities of long-term medical treatment become relevant. For this, there are several groups of drugs available, such as bisphosphonates to maintain bone tissue, calcium-sensing receptor agonists (calcium mimetics) that are effective in reducing blood calcium levels. The patients frequently require combined therapy to control the major manifestations of the disease. There are limited data on the long-term medical management of patients with manifest PHPT in the literature.

Histamine that belongs to one of the most important mediators involved in the regulation of the body's vital functions plays a great role in the pathogenesis of different diseases. Histamine is released during inflammatory and allergic reactions, anaphylactic and anaphylactoid shock, pseudoallergic reactions, and others. Acting through histamine receptors, it leads to increased intracellular concentration of cyclic guanosine monophosphate, enhanced chemotaxis of eosinophils and neutrophils, production of prostaglandins and thromboxane B, suppressed synthesis of lymphokines, etc. and causes contraction of smooth muscles of particularly the bronchi and intestine, dilation of vessels and their increased permeability, mucus hypersecretion in the upper airways, lower blood pressure, angioedema and itch, etc. In this connection, antihistamines that block histamine-induced reactions in various ways: by inhibiting its biosynthesis, enhancing its neutralization, blocking the access to receptors, and suppressing the release from mast cells, occupy a prominent place in clinical practice. The review covers the classification, main mechanisms of pharmacological action, and indications for the use of antihistamines that not only have the well-known antihistamine properties, but have also a broad spectrum of anti-inflammatory activity. There are data on the benefits of a group of antihistamines, the quinuclidine derivatives (quifenadine, sequifenadine) that were designed by Academician M.D. Mashkovsky and are one of the first examples of designing new classes of multifunctional non-sedating antihistamines, which combines a high selective activity to block histamine type 1 receptors and an ability to block serotonin and to break down histamine directly in tissues.

The paper discusses approaches to optimizing pharmacotherapy in patients with hypertension associated with cerebrovascular diseases. Possible indications for neuroprotectors and a pathogenetic rationale for their mechanism of action in patients with prior cerebral stroke are detailed.

The review deals with the current aspects of prevention of non-cardia gastric cancer (GC). Helicobacter pylori is the most common cause of non-cardia GC. The Correa cascade remains a major pattern of the pathogenesis of non-cardia GC as before. The key moments in gastric carcinogenesis are H. pylori infection; genes associated with cell recognition of bacteria; an immune response and the activation of an inflammatory response. The prevention of GC requires H. pylori eradication as primary prevention in combination with screening for this pathology as secondary prevention of gastric malignancies. Standard three-component therapy is a first-line major regimen for H. pylori eradication.

The paper reviews scientific publications on studies of the epidemiology, etiology, pathogenesis, and main clinical manifestations of panic disorders and approaches to their treatment.