Vol 95, No 5 (2014)

Theoretical and clinical medicine

Anticoagulant and fibrinolytic blood systems in patients with arterial hypertension stage III

Mirsaeva G.K., Khakimova R.A.


Aim. To measure the indicators of the anticoagulant and fibrinolytic blood systems activity in patients with arterial hypertension after suffering a hemorrhagic stroke. Methods. 82 patients with arterial hypertension were examined at different terms after suffering a hemorrhagic stroke. Antithrombin III activity, total blood fibrinolytic activity and D-dimer levels, as well as tissue plasminogen activator activity and antigen levels were studied. Patients were examined at admission before standard treatment initiation and at discharge. Tissue plasminogen activator activity and its antigen level were determined at admission. Statistical data processing was performed using Statistica 8 (StatSoft) integrated package for Windows. Results. Inhibited fibrinolytic activity and an imbalance of its components, as well as reduced levels and activity of antithrombin III and signs of fibrin formation were revealed in patients with arterial hypertension stage III at different periods after suffering hemorrhagic stroke. Changes were most evident in early and late recovery periods after suffered cerebral stroke. Subsequent follow-up for over-a-year term after suffered cerebral stroke revealed a trend for normalization of these indicators. The study of tissue plasminogen activator activity and levels of its antigen showed significant changes in these parameters. Analysis of the obtained results for all patients with hypertension, regardless of the period of hemorrhagic stroke, showed the reduction of the antigen tissue plasminogen activator level and its increased activity. After in-patient treatment, there was a trend for improvement in all studied parameters without their complete normalization. Conclusion. The results suggest an activation of intravascular clotting in parients with arterial hypertension who suffered a hemorrhagic stroke, increasing the risk for further cardiovascular complications.
Kazan medical journal. 2014;95(5):621-625
pages 621-625 views

Treatment compliance of elderly patients with chronic obstructive pulmonary disease

Malykhin F.T., Baturin V.A.


Aim. To study the compliance in patients with chronic obstructive pulmonary disease. Methods. The study included 95 in-patients of pulmonology unit with exacerbation of chronic obstructive pulmonary disease, in whom Morisky-Green questionnaire and interviews using modernized questionnaires were used to assess patients’ compliance. Results. The willingness to cooperate with a doctor was shown by 57.9% of patients, and 42.1% showed low motivation. An average compliance index was 2.44±0.16. The number of non-compliant males (61.4%) was 2.4 times higher compared to females (25.5%). Treatment compliance was associated with lower education level: good compliance was shown by 75.0% of patients with secondary education, 63.5% with special secondary education, and only by 50% of patients with higher education. However, among compliant patients with higher education, only 73.3% of patients had partial compliance, compared to 57.6% with special secondary education and 100% - with secondary education. Adherence to treatment in male smokers was 1.6 times lower compared to non-smokers. Patients often associated the omissions of taking medicine with forgetfulness in 37.9% of cases, with inattentive attitude to themselves in 22.1%, with fear of toxic and side effects and the desire to «rest» from treatment in 14.7% of cases. Conclusion. Higher compliance is typical for women more than men; for non-smoker males than smokers. Patients with specialized secondary education showed highest compliance.
Kazan medical journal. 2014;95(5):626-631
pages 626-631 views

Serum apelin-12 in bronchial asthma

Mineev V.N., Lalaeva T.M., Kuzmina A.A.


Aim. To evaluate the serum level of apelin-12 in patients with bronchial asthma. Methods. 11 healthy controls and 29 patients with bronchial asthma were examined (among them 19 with atopic asthma and 10 with non-atopic asthma). Serum apelin-12 levels were measured by enzyme immunoassay (ELISA, MyBioSource, USA). SPSS (Statistical Package for the Social Science, V. 13) for Windows was used for statistical analysis. Results. The phenomenon of low apelin-12 serum levels was revealed in patients with bronchial asthma. The most significant decrease of apelin-12 levels was noticed in atopic bronchial asthma. The apelin-12 levels were significantly correlated with a number of indices of bronchial obstruction. Apelin-12 levels correlated with a number of indicators characterizing the grade of bronchial obstruction. Moreover, low apelin-12 levels were suggesting bronchial obstruction. Besides, significant reverse correlation of apelin-12 levels and allergic sensitization was revealed. In addition, statistically significant relation between apelin-12 serum level and peripheral blood eosinophil and lymphocyte counts was revealed. There was an inverse association between apelin-12 serum level and peripheral blood neutrophil count. Conclusion. Literature analysis and our own results allow us to suppose the possible protective role of apelin-12 in bronchial asthma flare. Further studies of apelin-12 and of other isoforms of adipokines are needed for better understanding of the disease.
Kazan medical journal. 2014;95(5):631-636
pages 631-636 views

Extragenital diseases in patients with preterm delivery caused by preeclampsia and/or fetal growth restriction

Fadeeva N.I., Buryakova S.I., Belinina A.A.


Aim. To determine the influence of extragenital diseases and their combinations on the development of placental insufficiency manifesting as heavy preeclampsia and/or antenatal distress of fetus as indications for preterm delivery. Methods. The retrospective study based on medical charts of patients with delivery term of 28 to 36 weeks of gestation caused by heavy preeclampsia and/or antenatal distress of fetus was performed. Results. In case of the deliveries at 28-33 weeks of gestation caused by preeclampsia and fetal growth restriction, arterial hypertension was present in 42.8% of cases, combination of arterial hypertension and obesity - in 33.3%; at 34-36 weeks of gestation hypertension was revealed in 40%, obesity - in 22.5% of cases. In case of the deliveries at 28-33 weeks of gestation caused by preeclampsia, diabetes was present in 42.6% of cases, the combination of arterial hypertension and obesity - in 17.6%; at 34-36 weeks of gestation obesity was registered in 34.1% of cases. In patients with fetal growth restriction who delivered off at 28-33 weeks of gestation, arterial hypertension was diagnosed in 20.2% of cases; in patients who delivered off at 34-36 weeks of gestation, chronic diseases of upper respiratory tract were revealed in 21.4% of cases. Conclusion. The risk factors of pregnancy complicated by heavy preeclampsia and fetal growth restriction are arterial hypertension and obesity, whereas the combination of these factors increases the risk for pre-term delivery before 33 weeks of gestation eight-fold. The risk factors of pregnancy complicated by heavy preeclampsia without fetal growth restriction are diabetes mellitus type I and obesity (it increases the risk for pre-term delivery before 33 weeks of gestation four-fold if associated with arterial hypertension). The risk factors of pregnancy complicated by fetal growth restriction and antenatal distress of fetus are chronic diseases of upper respiratory tract, whereas arterial hypertension increases the risk of pre-term delivery before 33 weeks of gestation three-fold.
Kazan medical journal. 2014;95(5):636-641
pages 636-641 views

Cytokine profile of cervical mucus at different forms of papillomavirus infection

Skidanenko-Levina O.V.


Aim. To study the levels of pro- and anti-inflammatory cytokines in cervical secretion in females with cervical epithelial dysplasia and latent papillomavirus infection. Methods. The study included 120 females aged 20 to 40 years with cervical papillomavirus infection, who were assigned to two groups using «case-control» method. The first group included 60 females with latent disease, the second group - 60 females with mild and moderate cervical epithelial dysplasia (cervical intraepithelial neoplasia stages I and II). Cytokine levels in cervical secretion were measured by ELISA using «ProCon» test system. Results. ELISA test showed increased levels of interleukin-4 and interleukin-10 (43 [21; 74] and 48 [12; 88] pg/ml, respectively) and decreased levels of interleukin-2 (18.5 [5.5; 27.5] pg/ml), interleukin-6 (0.6 [0.06; 0.9] pg/ml), tumor necrosis factor alpha (88.5 [0; 123] pg/ml), interferon γ (2 [0; 4] pg/ml) in cervical secretion of females with cervical epithelial dysplasia compared to females with latent papillomavirus infection. Thus, females with cervical epithelial dysplasia showed increased levels of anti-inflammatory cytokines: interleukin-4 - by 2.7 times and interleukin-10 - by 2.4 times compared to females with latent disease, while levels of pro-inflammatory cytokines was decreased as following: interleukin-2 - by 1.4 times, interleukin-6 - by 4.5 times, tumor necrosis factor alpha - by 1.8 times, interferon γ - by 6.3 times (p <0.05). Conclusion. Imbalance of immune response cytokine regulation with anti-inflammatory cytokines prevailing might be an important factor facilitating persistence of papillomavirus in cervical epithelium and contributing to cervical epithelial dysplasia onset and progression.
Kazan medical journal. 2014;95(5):642-645
pages 642-645 views

Secretion level of some endogenous antimicrobial peptides and certain cytokines in type 2 diabetes mellitus

Azizova G.I., Gasanova S.I., Niyazova N.K., Dadashova A.R., Azizova U.G.


Aim. To assess plasma levels of antimicrobial peptides (defensin and endotoxin) and some cytokines (interleukin-6, tumor necrosis factor α and transforming growth factor β) in type 2 diabetes mellitus. Methods. Blood samples of 87 patients with type 2 diabetes mellitus were examined. All patients were assigned to three groups depending on blood glucose and glycosylated hemoglobin levels: compensation - 36 subjects, sub-compensation - 34 subjects, decompensation - 17 patients. Plasma levels of endogenous peptides - defensin (HNP) and endotoxin - were measured. Enzyme-linked immunosorbent assay test was used to measure the levels of cytokines («Bender Medsystems» kits, Austria) and antimicrobial peptides (set «Hycult Biotech»). Results. In the first group (diabetes mellitus type 2, compensation), defensin level was 120.0±0.9 ng/ml, which is 17.6% higher than in the control group. The second group (sub-compensation) showed a 4-fold increase in defensin level compared to the control, the third group (decompensation), defensin level was 1443.1%, or 14.4-fold compared to the control. Endotoxin level was 1.18±0.05 ng/ml in the first group, 1.57±0.14 ng/ml in the second group, and 18.2±0.09 ng/ml in the third group compared to 0.33±0.12 ng/ml in the control group. Patients with decompensated and sub-compensated diabetes showed statistically significant increase in plasma levels of interleukin-8, tumor necrosis factor α and transforming growth factor β compared to the controls. Conclusion. There was an interrelation revealed between the secretion of antimicrobial peptides and cytokines - interleukin-8, tumor necrosis factor α and transforming growth factor β; concentration of antimicrobial peptides and cytokines reflects the stage of development of type 2 diabetes mellitus.
Kazan medical journal. 2014;95(5):646-649
pages 646-649 views

Prognostic value of cell-mediated immunity changes in patients with diabetes mellitus and metabolic syndrome undergoing simultaneous surgical operations

Gerbali O.Y., Kostyrnoy A.V., Petrov A.V.


Aim. To study the prognostic value of cell-mediated immunity changes in patients with type II diabetes mellitus undergoing simultaneous operations for treatment of cholelithiasis and postoperative ventral hernias. Methods. Two groups of female patients with cholelithiasis and postoperative ventral hernias who underwent planned simultaneous surgical treatment were examined. The firs group included 48 patients with type II diabetes mellitus and abdominal obesity. The second group included 48 patients without diabetes mellitus and metabolic syndrome. Mononuclear leukocytes of peripheral blood were isolated by density gradient centrifugation on Ficoll-verografin. Relative and absolute number of lymphocyte populations and subpopulations and FAS-receptor expression were studied by indirect immunofluorescence using specific monoclonal antibodies. Apoptotic cells were determined by fluorescent microscopy after exposure of separated mononuclear leukocytes to DNA dye Hoechst 33342. Results. Patients with type II diabetes mellitus had higher incidence of purulent complications after laparoscopic cholecystectomy and surgical treatment of ventral hernias (14.6% vs. 2.0%, p <0.01), which was associated with absolute and relative decrease of CD4+ and CD16+ lymphocyte levels and immunoregulatory index and increased spontaneous and FAS-induced apoptosis of mononuclear leukocytes. In patients who developed purulent complications, more significant reduction of the absolute number of CD16+ lymphocytes (34.5±3.8×106/L vs. 76.72±5.16×106/L, p <0.01) and increased spontaneous apoptosis (7.9%±1.1% vs. 2.7±0.3% compared to patients without complications, p <0.01) was determined. Conclusion. Immunological predictors for developing postoperative purulent complications after simultaneous abdominal surgeries in patients with type II diabetes include decreased indicators of spontaneous apoptosis and decreased number of NK-cells.
Kazan medical journal. 2014;95(5):650-654
pages 650-654 views

Statherin saliva levels in patients with dental caries

Yavgil’dina D.A., Saleev R.A.


Aim. To examine the influence of statherin on the rate of dental diseases and to determine the concentration of salivary staterin in patients with dental caries. Methods. The study recruited 134 persons, including 54 patients with dental caries and its complications (experimental group) and 80 healthy volunteers (control group). Pateints’ mean age ranged from 18 to 42 years. A comprehensive dental examination of all subjects was carried out, hygiene indexes were defined, complete dental history was gathered. Whole unstimulated saliva was examined. Statherin saliva level was determined using an enzyme-linked immunoassay test. To study the relationship between statherin saliva level and studied dental clinical features (amount of teeth with caries, sealed and extracted teeth, age, hygiene indices, eating and smoking habits, xerostomia), Spearman nonparametric rank correlation test was used. Results. Statherin saliva level was higher in patients with dental caries and its complications compared to healthy controls. Mean saliva statherin concentration was Me=6.1 [2.5, 18.4] mmol/l in patients with caries compared to Me=3.5 [2.9, 7.3] mmol/l in control group. There was no statistically significant differences of saliva staterin concentrations between men and women in both groups. Oral hygiene (as defined by simplified oral hygiene index), food consumption (right after a meal or 4 hours after a meal), bad habits (smoking) had no effect on statherin concentrations in saliva. Conclusions. Statherin saliva levels are indicative of the diseases of the oral cavity.
Kazan medical journal. 2014;95(5):654-657
pages 654-657 views

Medical waste monitoring in a dental outpatient clinic

Khasanova I.K., Khakimov N.M., Zakirov I.G., Zorina L.M., Timerzyanov M.I., Shakirov R.R.


Aim. To estimate the amounts and weight of medical waste in the dental outpatient clinic. Methods. Amounts and weight of types A and B medical waste, as well as the number of patients treated in the branch №1 of OAO «City Dentistry», Kazan, Russia from June 2012 to May 2013 were analyzed using the methods of public health statistics. Results. Total amount of type A medical waste was 7516 pieces, with the average amount of 300.6±9.21 per month. Total weight was 8995.3 kg, with the average of 359.8±11.03 kg per month. Total amount of type B medical waste was 6804 per year, with the average of 272.2±5.19 per month, and their total weight was 12090.6 kg, with the average of 483.6±13.39 kg per month. Despite the trend of increasing the absolute amounts and weight of type A and B waste, if calculated per patient treated, these values had a trend for reduction. Medical waste amounts differed between the departments of the outpatient clinics, even between departments providing same medical care. In general, types A and B waste weight was increasing, while amount of waste decreased. Conclusion. Types A and B waste weight depended mainly on the number of treated patients compared to waste amount. Waste weight and amount, if calculated per patient treated, had different trends and were different not only between the departments of surgery, orthopedics and conservative dentistry, but also between different departments of conservative dentistry.
Kazan medical journal. 2014;95(5):658-663
pages 658-663 views

Using visual evoked potential test for revealing lies about drug intake

Zhbankova O.V., Gusev V.B., Sazonova A.A.


Aim. To study the features of visual evoked potential in potential military recruits for revealing lies about drug intake. Methods. 114 subjects were examined. Electroencephalography, urine test for drug traces, polygraph test were performed to reveal the risk factors for drug intake. All subjects were allocated to three groups. First group included potential military recruits who were not taking drugs (34 subjects, 29.8%). Second group included potential military recruits who tried psychoactive drugs for 1-5 times, but in whom no risk factors were revealed on polygraph test (21 subjects, 18.4%). Third group included potential military recruits who tried psychoactive drugs for 5-15 times, and in whom risk factors were revealed on polygraph test (31 subjects, 27.2%). Fourth group included potential military recruits who tried psychoactive drugs for 5-15 times, and had marked risk factors according to polygraph test (28 subjects, 24.6%). Psychoactive substance traces were revealed by urine test in 8 subjects. Graphical representations of different situations associated with drugs intake were used as a stimulus at visual evoked potential test. Results. Changes in visual evoked potential test as a response to a slideshow depicting situations associated with drugs intake might be seen in potential drug addicts long before stereotyping the drug abuse. The most informative parameters of evoked brain activity are amplitudes of 250-550 ms, where a statistically significant difference between the amplitudes of visual evoked potentials in individuals with and without history of drug abuse was revealed. The amplitude of P300 wave in individuals who do not use drugs was significantly higher compared to drug abusers. Software allowing to predict the higher chance of possible drug abuse was developed at the basis of the research. Conclusion. The method of visual evoked potentials showed high predictive value for the diagnosis of drug abuse among possible military recruits; obtained results might be used in the professional selection of persons in hazardous occupations.
Kazan medical journal. 2014;95(5):664-669
pages 664-669 views

Functional properties of mesenchymal multipotent stromal stem cells obtained from bone marrow of patients with liver cirrhosis

Agaev B.A., Agaev R.M., Popandopulo A.G., Dzhafarli R.E.


Aim. To study of the functional properties of autologous mesenchymal multipotent stem cells in patients with cirrhosis of different etiologies. Methods. Studied were the functional and phenotypic properties of autologous mesenchymal stem cells derived from the bone marrow in 35 patients (26 men and 9 women) with cirrhosis of the liver at the age of 19-53 years. Among the patients studied viral etiology was diagnosed in 18 (51.4%), alcohol - in 13 (37.1%), autoimmune - in 4 (11.4%) patients with liver cirrhosis. Results. Autologous mesenchymal stem cells from all of the observed patients were able to divide. The highest yield and the doubling rate of cell populations were observed in patients with viral cirrhosis. Comparative morphometric study of primary cultures derived stem cells in patients with autoimmune and alcoholic hepatitis, showed the presence of relatively small cells (less than 20 microns), which make up about 30% of the total number of cells. At the same time, in bone marrow derived cell cultures of patients with viral etiology of the disease the number of small cells was 1.5 times greater which makes approximately 49% of the total cell population. The vast majority of cultured stem cells, regardless of the etiology of cirrhosis express specific for these cells «stromal» markers - CD73, CD90 and CD105. Autologous mesenchymal stem cells isolated from bone marrow of patients with alcoholic liver cirrhosis characterized by the most pronounced pro-inflammatory, immunoregulatory potential. Conclusion. Functional and phenotypic properties of autologous mesenchymal stem cells in various forms of cirrhosis are different which requires adequate cultivation and correction before their transplantation.
Kazan medical journal. 2014;95(5):669-674
pages 669-674 views

Experimental assessment of potassium ions diffusion speed from new gel reducing dental sensitivity

Kozmenko A.N., Belokonov N.A.


Aim. To compare the contents of potassium salts in specialized toothpastes, and to estimate the possibility for potassium ions diffusion through dentinal tubules after firm tooth tissues conditioning by a toothpaste containing fluoride. Methods. Toothpastes specially formulated to treat the pain of sensitive teeth: «Sensodyne F» (contains potassium chloride); «PresiDENT Sensitive» (potassium nitrate); «Asepta Sensitive» (potassium citrate) and new gel reducing dental sensitivity (contains potassium chloride) were examined. Speed of potassium ions diffusion through dentinal tubules after firm tooth tissues conditioning by a toothpaste containing fluoric substances were measures by potentiometry and a special device using tooth slice as a membrane. Results. Considering that toothpaste is applied within 5 minutes, while gel - within 15-20 minutes, it is possible to assume that potassium ions bioavailability from 1 g of gel can be assessed as 41 mg, compared to 5.9±0.5 mg from 1 g of paste №1, 0.4±0.05 mg - №2; 7.8±0.5 mg - №3. So, potassium ions bioavailability from 1 g of gel is 7; 102; 5 times higher (respectively) compared to toothpastes. Speed of potassium ions diffusion through dentinal tubules ranged between 0.2 to 1.64 μg/min and depended on the number of membrane potassium channels permeable for potassium. Fluoride toothpastes specially formulated to treat the pain of sensitive teeth reduced the speed of potassium ions diffusion from the solution by 4-7 times by blocking the dentinal tubules. This can be also associated with fluoride-containing protective film formation. Therefore, at the first stage of treatment of teeth hypersensitivity using new gel, it is better to use a toothpaste without fluoride. Conclusion. Compared to the examined toothpastes, new gel for reducing dental sensitivity contains higher number of potassium free ions, which can enter dentinal tubules reducing the effect on free nerve endings. Potassium ions diffusion through dentinal tubules reduced 4-7-fold after conditioning by a toothpaste containing fluoride.
Kazan medical journal. 2014;95(5):675-679
pages 675-679 views


Oral mucosa lichen planus: clinical forms, treatment

Chuykin S.V., Akmalova G.M.


Despite the fact that lichen planus was firstly described over 150 years ago, the disease still remains an important issue of clinical dentistry. The article reviews the clinical features of various forms of oral mucosa and vermilion border lichen planus: typical, hyperkeratotic, exudative and hyperemic, erosive with ulcerations, bullous and atypical. The main pathologic element in all forms of lichen planus is papule of milky white or grayish color. Papules may be single or merge into intricate carvings forming lace, mesh, fern leaves (Wickham mesh). Compared with skin forms, oral mucous membrane lesions are more resistant to medical treatment and rarely undergo spontaneous remission. Treatment of lichen planus is a difficult task because the etiology and pathogenesis of the disease is not completely understood. This article reviews the methods and drugs used to treat oral mucosa lichen planus, and their side effects. At the moment, no single method of treating lichen planus can be considered as a cure. Existing comprehensive treatments help to reduce severity of the disease, which is seen as prolongation of remission, reduction of terms of pathological elements epithelialization, reduction of their number and size. To achieve consistent results in the treatment of oral mucosa lichen planus, complex treatment should be periodically repeated. Selection of optimal methods of general and local therapy should be based on an individual approach to each patient.
Kazan medical journal. 2014;95(5):680-687
pages 680-687 views

Diagnostic imaging techniques for diagnosing bone metastases of non-small cell lung cancer

Laryukov A.V., Laryukova E.K.


Lung cancer bone metastases hold one of the leading positions. At the same time, data of the rate of lung cancer bone metastases are scarce. Clinical symptoms of bone metastases in the early stages may be missing. Time of bone metastases appearance, as well as localization depending on the size of primary lesion and its histological structure are not well-covered. According to domestic and foreign literature data, the advantages and limitations of radiological and nuclear methods in detecting bone metastases of non-small cell lung cancer are presented, their resolution and sensitivity are discussed. The analysis of comparative results of various diagnostic imaging techniques in detecting lung cancer bone metastases (X-ray, bone scintigraphy, computed tomography, magnetic resonance imaging, single-photon emission computed tomography, positron-emission tomography) is of undoubted interest. These data are necessary for choosing the appropriate diagnostic tactics and selecting an adequate sequence of using high-tech radiology methods for early detection of lung cancer bone metastases. However, the comparative data presented in the literature are generally based on a scarce clinical material; mostly comparisons of diagnostic capabilities of only two methods were held. There is no data on the rate of bone metastases of peripheral non-small cell lung cancer and its association with the localization, size and histological structure of the primary tumor.
Kazan medical journal. 2014;95(5):687-692
pages 687-692 views

Ovarian stromal hyperthecosis

Khasanov A.A., Zhuravleva V.I., Lipatova I.O.


The review analyzes the data on pathogenesis, prevalence, pathomorphology, clinical manifestations, diagnosis and treatment of ovarian stromal hyperthecosis. This condition is characterized by severe hyperandrogenism and impaired glucose tolerance, and it is mostly occurs in postmenopausal women. Main cause of androgenic hyperproduction in women of reproductive age - the polycystic ovary syndrome - is thoroughly studied; standards for diagnostics and treatment for such patients are developed. Little is known about stromal hyperthecosis, which is a more rare cause of hyperandrogenism that had been considered as a severe form of polycystic ovary syndrome. However, it became an independent nosological form after a detailed study of the pathomorphology. Currently, there are no generally accepted diagnostic criteria for stromal hyperthecosis. This is not only because the disease is rare, but also due to the difficulty of making the final diagnosis. Patients with stromal hyperthecosis are at high risk for developing malignancies - endometrial cancer or breast cancer. So, the need for further investigation and developing treatment approaches is undoubted. In majority of cases, the diagnosis of stromal hyperthecosis is set on histological examination of ovarian tissue from patients with idiopathic severe hyperandrogenism, infertility or cancer. The practicing obstetrician-gynecologist must be aware of this condition to suspect the ovarian stromal hyperthecosis when its typical clinical features manifest, to perform meticulous laboratory and instrumental investigation and to choose the correct management tactics for such patients.
Kazan medical journal. 2014;95(5):692-696
pages 692-696 views

Social hygiene and healthcare management

Experience of the Republic of Tatarstan in the implementation of early intervention model to support infants with developmental disorders and disabilities

Farrakhov A.Z., Ignashina E.G., Sadykov M.M., Zubova E.P.


Aim. To evaluate the effectiveness of implementing the program of early intervention in the Republic of Tatarstan, which provides medical and psycho-pedagogical support of infants with developmental disorders and disabilities. Methods. The following methods were used: analytical, expert, comparative and systematic approach. Results. Gained results indicate the high efficiency of new forms and approaches for supporting infants with diseases and developmental disabilities with a focus on early intervention techniques in a background of phased health care. The advantages of an embedded algorithm of prenatal diagnosis of development disorders in children, as well as neonatal screening for hereditary pathology of infants, audiologic and electrocardiographic screenings of newborns, are shown, allowing timely diagnosis and early correction of disorders, including high-tech methods use. The positive trends of the performance of early intervention offices in children’s’ outpatient departments are stressed, resulting in infants harmonious and optimal neuro-psychological development and improvement of their quality of life. The positive aspects of children’s rehabilitation institutions of social security system activities are highlighted, which include the use of modern technologies of medical and social rehabilitation. The positive changes of disability rate for many nosologic forms, mortality, as well as the number of cases of abandoned newborns, were registered. Conclusion. Implementing the program of early intervention provides an opportunity to influence the health status and quality of life in infants with developmental disabilities and handicapped infants, to promote their social integration, to prevent disabilities in infants and parents refusals to educate their children (social orphanage).
Kazan medical journal. 2014;95(5):697-702
pages 697-702 views

Gender features of age-related risk of mortality associated with nervous diseases

Mamedbeyli A.K.


Aim. To explore the hypothesis of equal age-related risk of mortality associated with nervous diseases in females and males. Methods. Descriptive statistics, qualitative analysis were performed. 13 580 medical certificates of cause of death, all related to nervous diseases (all classes of ICD-10) were analyzed. Results. The mortality rate increased with age. Age-specific mortality rates had gender differences. In most ages (20-24, 30-34, 45-49, 50-54, 55-59, 65-69), mortality rate was higher in males, at the age of 5-9, 15-19, 60-64, 70 and over - in females. Death relative risk in males of different age groups (compared to the similar rates in females) varied between 0.39 (in the age group of 5-9 years) to 5.93 (in patients aged 20-24 years). Overall, the level of mortality associated with nervous diseases was 130.02±1.69 per 100 000 in males and 163.41±1.86 per 100 000 in females, so, overall mortality rate was 1.25 times higher in females. After adjustment for age differences was performed, no significant differences were found between the groups (146.74 and 144.16 per 100 000 respectively for males and females). Conclusion. Gender features of age-related risk of mortality associated with nervous diseases were characterized by multidirectional alterations of mortality rates and share of nervous diseases among all reasons of mortality. These features were mainly caused by situational factors (different age structure and overall mortality level for males and females), and vanished after adjustment.
Kazan medical journal. 2014;95(5):703-705
pages 703-705 views

Examination and hygienic assessment of health risk depending on heavy metals content in foods

Kazimov M.A., Alieva N.V.


Aim. To determine total daily intake and absorbed doses of some heavy metals with subsequent hygienic assessment of health risks associated with exposure to them. Methods. To determine the levels of heavy metals (lead, cadmium, chromium, nickel, copper and zinc) in food products included in the daily diet, actual nutritional status of 57 individuals was studied using questionnaire survey method in accordance with the existing guidelines. Samples of 18 food items were chemically analysed. Bio-materials (blood and hair) taken from randomly selected study subjects were analysed to determine the levels of heavy metals. The heavy metal levels in food products and biological media were determined by atomic absorption spectrometer («Shimadzu», Japan). Actual intake and absorbed daily doses of heavy metals were calculated using the quantitative data on the daily diet and metal levels in individual products according to the existing guidelines. Health risk values were estimated based on the gained results. Results. Various levels of heavy metals in food products were revealed. Their ranking order by levels present in basic food products (in bakery and meat products) is as follows: Zn >Cr >Ni >Cu >Pb >Cd. High levels of heavy metals intake with daily diet (compared with the reference values) were revealed. Furthermore, high absorbed doses of heavy metals, particularly chromium and nickel, were accompanied by increased concentrations in blood and hair. The dose risk ratios for chromium and nickel were assessed as 1.31 and 3.77 respectively (for other metals - 0.15-0.58). Conclusion. The daily dietary intake and absorbed doses of chromium and nickel represent respectively low and increased risk to human health among the studied heavy metals.
Kazan medical journal. 2014;95(5):706-709
pages 706-709 views

History of medicine

Organization and financing of the zemstvo health care in the Kazan province

Morozova E.V., Sozinov A.S.


«The Statute on the provincial and district local government» (1864) started a significant social and economic changes in the country. Before the introduction of zemstvo self-government the organization of health care was administered by various departments. So there was no unified system of health care provision. With the introduction of the territorials authority in the area of «national health» were divided between governmental and territorial authorities. State management covered issues of sanitary improvement and anti-epidemic measures. The task of medical care organizing was on the territorial self-government, although they did not have sufficient administrative permissions. Throughout the whole period of activity the territorials created various administrative authorities for the organization of the effective system of management: the provincial and district councils of public health, provincial and district committees of public health, medical boards. Financing of the health care system was negligible in the early years of territorials. It was carried out from the provincial and district territorial budgets, with major financial expenses fell on the county local governments. They paid for the costs of the medical personnel and medical facilities, carrying out sanitary measures. Most of the funds were spent on treatment measures. The organization of an emergency anti-epidemic measures in case of the threat of spreading epidemics as well as the organization of mental health care and provision of the provincial hospital and paramedic school were funded from the provincial budget. The amount of financing of the territorial health care increased almost annually, reflecting the strategic importance of the health care sector for territorial self-government.
Kazan medical journal. 2014;95(5):710-714
pages 710-714 views

Hot issues of infectious deseases

Predicting adherence to antiretroviral therapy in HIV-infected patients

Fedyaeva O.N., Yushchuk N.D., Sirota N.A.


Aim. To develop a way for predicting adherence of HIV-infected patients to antiretroviral therapy, applicable in medical practice. Methods. The survey included 280 patients with verified diagnosis of HIV infection stage 3-4B, receiving antiretroviral therapy. Clinical manifestations of HIV infection and laboratory data were evaluated. Psychological testing using a Sheehan self-rating scale of anxiety was conducted. Statistical processing was performed using SPSS (version 17) statistical software package. Results. Among the factors that were not related to the primary disease (HIV), risk factors for non-compliance were: single/unmarried status of the patient and living on parents; no higher education. Factors associated with medical treatments included no motivation for switch from one treatment regimen to another, and a high drug load while receiving therapy (more than 7 pills a day). Presence of polyneuropathy on stage 4B and fever of unknown origin at stage 4B were also affecting compliance to antiretroviral therapy. Among laboratory signs, anemia and the level of viral load (independently on the stage of HIV infection), and the number of CD4+-lymphocytes in stage 4A affected the compliance. Assessment of anxiety in HIV-infected patients by using Sheehan self-rating scale of anxiety was more informative. Conclusion. The questionnaire was formed based on the identified factors. Each of the answers to the questionnaire’s questions is assessed by the coefficients of it influence to the adherence to antiretroviral therapy. The obtained data form the basis of the developed algorithm for determining adherence to antiretroviral therapy.
Kazan medical journal. 2014;95(5):715-721
pages 715-721 views

Clinical and laboratory features of infectious mononucleosis caused by the Epstein-Barr virus

Gileva R.A., Hohlova Z.A., Chechet Y.S., Arsenenko A.S., Povolotskaya L.M.


Aim. To study the clinical and laboratory characteristics of patients with infectious mononucleosis caused by the Epstein-Barr virus. Methods. In infectious hospital under observation there were 108 patients aged from 11 months to 31 years with a laboratory confirmed diagnosis of «infectious mononucleosis caused by the Epstein-Barr virus». Standard laboratory tests for blood serum immunoglobulin M to the capsid protein of Epstein-Barr virus, immunoglobulin class G proteins to early Epstein-Barr virus and the index of their avidity by ELISA were carried out. Tests for other infections were conducted if it is required. Results. Patients dominated by children aged 1-7 years - 73.1%. Adult patients was 1.8% (2 patients). Only 4.6% of the patients were sent to the hospital with a diagnosis of «infectious mononucleosis» or suspected of having the disease. The typical clinical picture of infectious mononucleosis was observed in 75% of cases, atypical - in 25%. Mononuclear cells in peripheral blood were found in less than half of the patients (44.4%), in 53.1% of cases with typical and in 18.5% of cases with atypical clinic. In the remaining patients, the diagnosis of infectious mononucleosis was verified by ELISA. In 90.4% of the cases the disease was in the moderate, and in 9.6% - in the severe form. Conclusion. The high frequency of atypical course of infectious mononucleosis caused by the Epstein-Barr virus justifies the need to include it into differential diagnosis process in case of unclear infectious disease, to identify the antibodies to the Epstein-Barr virus proteins, (immunoglobulin M and G) and the index of avidity antibodies (immunoglobulin G).
Kazan medical journal. 2014;95(5):722-725
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The organization of medical care for patients with chronic viral hepatitis in the Republic Sakha (Yakutia)

Sleptsova S.S., Tihonova N.N., Semenova V.K., Rahmanova A.G.


Aim. To identify the risk factors for primary liver cancer in patients with chronic viral hepatitis in the Republic of Sakha (Yakutia) and develop an organizational model of treatment and prevention of viral hepatitis and primary liver cancer. Methods. Clinical, epidemiological and molecular biological methods were used. Results. There is a high prevalence of chronic viral hepatitis B, C and D in the Republic of Sakha (Yakutia), as well as their distant adverse outcomes. Disclosed the problem of the combined effects of risk factors for primary liver cancer in people indigenous nationality of the Republic of Sakha (Yakutia), mostly male, living in rural areas, which is the simultaneous replication of hepatitis viruses B, C and D in patients with genetically predisposed changes in the activity of alcohol dehydrogenase and aldehyde dehydrogenase. The modernization of the training algorithms of patients for liver transplantation and management of patients with cirrhosis and liver cancer in the outcome of chronic viral hepatitis, liver transplantation is justified from a related donor with a high level of specific antibodies of patients with primary liver cancer, as well as phasing held medical diagnostic and organizational and methodological measures. Created was an annual Republican «liver-school» for physicians, gastroenterologists, internists, pediatricians, epidemiologists, introduced the publication of conference materials for use on the entire territory of the Republic of Sakha (Yakutia). Conclusion. Multi-component structural-functional model of service prevention and control of viral hepatitis has allowed to develop a program to address the medical and social protection of different groups of the population to create a unified register «Chronic viral hepatitis in the Republic of Sakha (Yakutia)», as well as long-term programs for complex vaccine prophylactics and modernization of services for prevention and control of viral hepatitis.
Kazan medical journal. 2014;95(5):726-730
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Characteristics of extreme increase of vector-borne infections in the european north

Burmagina I.A., Agafonov V.M., Burmagin D.V.


Aim. To describe clinical and epidemiological situation of the massive increase of cases of vector-borne infections and the level of preventive and antiepidemic measures in the Archangelsk region over the last decade. Methods. Retrospective, longitudinal study investigated ten-year incidence of vector-borne infections, vaccination of the population and the amount of disinfection measures in the region over the last decade. Results of a survey of 232 citizens, who were referred for vaccination against tick-borne encephalitis, are listed. The study included 101 patients with tick-borne encephalitis, 19 of which had concomitant a tick-borne Lyme disease, and 21 patients with tularemia treated in infectious hospitals of Archangelsk between 2011 to 2014. Results. Observations performed over the last decade showed marked increase in the incidence of vector-borne infections among the population of the Archangelsk region Levels of immunization against tick-borne encephalitis has also increased, level of vaccination against tularemia was unstable. Amounts of disinsectization measures tends to increase, but the number of people bitten by ticks also progressively increases. None of patients diagnosed with tick-borne encephalitis and tularemia who got the disease in the Archangelsk region had been previously vaccinated. The survey of 232 citizens showed sustainable motivation for vaccination, therefore, regional program for children and adult vaccination should be facilitated, considering the increasing incidence of vector-borne infections in non-vaccinated subjects. Predominant clinical forms were feverish and severe focal for tick-borne encephalitis, erythema for Lyme disease and bubonic for tularemia. Due to climate change, incidence of vector-borne infections over the last decade was on stable upward trend with high share of severe forms and high risk for progredient clinical course. Conclusion. Preventive and antiepidemic measures in the Archangelsk region over the last decade tend to increase, but are still not enough effective, as do not lead to a significant reduction of incidence.
Kazan medical journal. 2014;95(5):731-735
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Features and role of lipid peroxidation in patients with chronic hepatitis C (genotype 1b) before and after antiviral therapy

Konstantinov D.Y., Suzdal’tsev A.A.


Aim. To estimate the levels of lipid peroxidation products in erythrocytes of patients with chronic hepatitis C (genotype 1b) before the initiation of antiviral therapy and after its completion. Methods. The study included 195 patients with chronic hepatitis C (genotype 1b). The levels of conjugated dienes, triene ketones, Schiff bases and oxidation index were measured after extraction of erythrocyte membranes with chloroform/isopropanol (2:1) mixture according to I.D. Stal’naya method modified by I.A. Volchegorskiy. All patients were allocated to four groups depending on the alanine transaminase activity prior to antiviral therapy: the first group (n=52) - with normal levels of the enzyme, the second (n=74) - with elevation not exceeding 3 normal ranges, the third group (n=42) - 3 to 5 normal ranges, the fourth group (n=27) - exceeding 5 normal ranges. Antiviral treatment included pegylated interferon alfa-2b and ribavirin for 48 weeks. Results. Level of conjugated dienes, triene ketones, Schiff bases and oxidation index were ranged from 0.71±0.04 to 1.02±0.03, from 0.45±0.08 to 0.94±0.02, 0.17±0.04 to 0.41±0.04 and from 0.91±0.13 to 1.91±0.03 units respectively, which was significantly higher than normal ranges and was directly dependent on the alanine transaminase activity. In addition, in patients who did not respond to antiviral treatment, these parameters were significantly higher compared to patients with immediate virologic response (p <0.01). Conclusion. Patients with chronic hepatitis C had increased levels of lipid peroxidation products in erythrocytes; their high content in patients who did not respond to antiviral treatment may be a predictive factor for antiviral treatment effectiveness.
Kazan medical journal. 2014;95(5):736-739
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Educational process management in HIV medicine in Saint Petersburg

Rakhmanova A.G., Yastrebova E.B.


The stages of the Department of socially significant infections formation, starting from the training course for laboratory diagnosis of acquired immunodeficiency syndrome (AIDS) at the Department of Infectious Diseases, scientific, educational and practical association «AIDS and AIDS-defining illnesses» at the Medical Academy of Postgraduate Education (nowadays - Northwest Medical University), approved by the order of Healthcare ministry of USSR №467 in 1987, which in 1992 came under the jurisdiction of Russia, headed by Professor A.G. Rakhmanova, up to creating the Department of the Pavlov First Saint Petersburg State Medical University. In the late 90s and early this century, Department of Infectious Diseases with the course of the AIDS laboratory diagnosis was virtually the only one in the country for training on human immunodeficiency virus (HIV) infection, its laboratory diagnostics and other related diseases. As a result of scientific, educational and practical association «AIDS and AIDS-defining illness» activity, for over 20 years scientific staff was trained on HIV Medicine and associated socially significant infections. As a part of that effort, more than 25 doctors of science and 60 PhDs who are currently teaching HIV medicine and associated co-infections: chronic viral hepatitides, tuberculosis, herpes and other diseases in Russia and countries of the former post-Soviet space, were trained. The next step was the establishment of «HIV Medicine» course in 2009 in the Pavlov First Saint Petersburg State Medical University, and later in 2013 - creation of an independent Department of socially significant diseases.
Kazan medical journal. 2014;95(5):739-743
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Hospital-acquired acute viral hepatitis C

Suranbaeva G.S., Murzakulova A.B., Anarbaeva Z.A., Zhakisheva E.M.


Aim. To investigate clinical, epidemiological and laboratory features of acute viral hepatitis C hospital outbreak, registered in Aksy District, Kyrgyz Republic. Methods. The study was performed at department of infective diseases of Aksy Territorial hospital. 20 patients with acute hepatitis C were surveyed. All these patients were treated in the department of neurology of the same hospital (first one was admitted on 31.07.2006, last one - on 06.10.2006) for the mean term of 32 days before being admitted to the department of infective diseases. Epidemiologic, clinical and biochemical, serologic, virologic and instrumental methods were applied. Results. Acute hepatitis C was present as single infection in 19 cases, in was case it was associated with presence of surface antigen of the hepatitis B virus (HBSAg). All patients with acute hepatitis C had typical clinical pattern of the disease, moderate disease severity was the most common. Epidemiologic investigation revealed that all these patients while beain treated at the department of neurology, got injections using disposable syringes, no acupuncture was administered. None of them had parenteral and surgical interventions, blood transfusions, dental treatments 6 months prior to the admission. All of them denied any contact with any patients with known hepatitis C. One patient had survived acute viral hepatitis in childhood. It appears that this hepatitis C infection outbreak was related to parenteral transmission because all patients were admitted to the infectious department from a neurologic department only and all reported a history of receiving intravenous drugs.
Kazan medical journal. 2014;95(5):744-747
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Modern aspects of differential diagnosis of the Crimean-Congo hemorrhagic fever

Cherenova L.P., Galimzyanov H.M., Vasilkova V.V., Cherenov I.V.


Aim. To lay down criteria for the differential diagnosis of Crimean-Congo hemorrhagic fever with a number of natural focal diseases prevalent in the Astrakhan region. Methods. A retrospective analysis of clinical, epidemiological and laboratory data of patients with Crimean-Congo hemorrhagic fever (74 cases), Astrakhan rickettsial fever (75), Q fever (75) and leptospirosis (25) was carried out in 2000-2013. Results. The basic clinical symptoms characteristic of the Crimean-Congo hemorrhagic fever for the differential diagnosis of Astrakhan rickettsial fever, Q fever and leptospirosis were distinguished. The early diagnosis of Crimean-Congo hemorrhagic fever was based on the epidemiological data taking into account spring-summer seasonality of the disease, patient’s visits to countryside, contact with animals, and data about tick bites and contact with ticks. Timely prescription of adequate antiviral and pathogenetic therapy helped to reduce the rate of severe forms and mortality from Crimean-Congo hemorrhagic fever. Conclusion. Differential diagnostic features of Crimean-Congo hemorrhagic fever were: the presence of the primary affect on the site of the tick bite, high body temperature, two-wave fever, significant signs of intoxication, the relative and absolute bradycardia, hemorrhagic rash, abdominal bleeding, changes of peripheral blood - leukopenia and thrombocytopenia.
Kazan medical journal. 2014;95(5):748-751
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Clinical and biochemical rationale for ozone therapy in patients with chronic viral hepatitis B and C

Galeeva N.V., Fazylov V.K., Valeeva I.K.


Aim. To explore the clinical and pathogenic role of lipid peroxidation, protective antioxidant system in association with biochemical indicators of liver functional state, and the effect of intravenous ozone therapy on these processes in patients with chronic viral hepatitis B and C, with the presence of liver cell cytolysis. Methods. Lipid peroxidation, antioxidant protection and biochemical indicators of liver functional state and their relation to liver functional state were studied in 184 patients with chronic viral hepatitis B and C using comprehensive clinical and biochemical methods. Intravenous ozone therapy was used in 50 patients with chronic hepatitis B and C to correct membrane disaorders. Results. Ozone therapy has shown a positive effect on lipid peroxidation processes and activity of antioxidant system, stimulating oxygen-dependent processes, improving liver function and well-being of patients with chronic viral hepatitis B and C. The association between lipid peroxidation products blood level and the intensity of liver cell cytolysis was revealed, there was no such association with the viral load level. Conclusion. In patients with chronic viral hepatitis B and C with active liver cell cytolysis, ozone therapy leads to clinical remission and normalizes liver functional state, lipid peroxidation and antioxidant enzymes activity.
Kazan medical journal. 2014;95(5):751-756
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Clinical characteristics of chronic hepatitis C in children with natural course of the disease

Leonova G.F.


Aim. Identification of the clinical features of chronic hepatitis C in children with the natural course of the disease. Methods. Examined were 168 children with chronic hepatitis C in the age of 0-17 years. Features of chronic hepatitis C was determined by the manifestation of infection, duration of disease, route of infection, objective data, the results of clinical and laboratory, instrumental and morphological studies of the dynamics for the period 2000-2013. Results. Depending on the variant of the infection, all children were divided into two groups: those with asymptomatic (121 patients, 72%) and manifest (47 patients, 28%) forms. Asymptomatic chronic hepatitis C in children characterized by the absence of complaints, normal values of alanine aminotransferase (36.4% of cases) and the minimal viral load (38.8% of cases). The clinical picture of chronic hepatitis C in children with manifest course characterized by the presence of clinical symptoms of low intensity as astenovegetatic (55.3%) and dyspeptic (55.3%) syndromes and extrahepatic manifestations (22.3%). According to the elastometry in more than half of the children (58.2%) liver fibrosis was identified. In 3 children in early childhood (up to 3 years) there was the elimination of the virus. Conclusion. Chronic hepatitis C in children in 72% of cases is asymptomatic; manifest form of chronic hepatitis C differs from asymptomatic form by a faster rate of disease progression.
Kazan medical journal. 2014;95(5):757-762
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Microbiota, biofilms and Helicobacter pylori in the diseases of gastroduodenal zone

Isaeva G.S., Ziatdinov V.B.


Large number of bacteria inhabits the human body. Alterations of microbiota can be involved in the pathogenesis of various diseases. The gastric microbiota consists of bacteria from 7 to 9 phyla, predominantly Proteobacteria, Bacteroidetes, Actinobacteria and Fusobacteria. Some populations are known as «matrix-enclosed microbial communities», which adhere to biological and artificial surfaces. Formation of bacterial biofilms is implicated in many chronic diseases. Growth of microbial biofilm may lead to commune resistance to the immune defense of the host and antimicrobial drugs. Reports about Helicobacter pylori interactions with other microorganisms and influences on the composition and the structure of the gastric microbiota, are contradictory. This review summarizes current knowledge of the association of bacterial communities with gastroduodenal pathology. Recent studies suggest the involvement of the microbiota in the development of gastric cancer and the researches on animal models support this hypothesis. Excessive bacterial growth causes an accumulation of endogenous N-nitrosocompounds (N-nitrosoamines and N-nitrosoamides), which are the potential carcinogens. Antagonistic activity of bifidobacteria, lactobacteria and saccharomyces is used against Helicobacter pylori in the complex antibacterial therapy supplemented with probiotics and synbiotics. With the application of the sequencing the metagenomics and single cell genomics, we could further understand the composition and the properties of microbiota, the role in the mechanisms of the pathogenesis of the stomach and the duodenum, develop the new diagnostic and therapeutic tactics for the patients with gastroduodenal diseases.
Kazan medical journal. 2014;95(5):762-768
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Anemia of chronic disease in patients with HIV infection: clinical and laboratory characteristics

Hasanova G.R., Mustafin I.G.


Aim. To provide clinical and laboratory characteristics of anemia of chronic disease in HIV infection in order to improve its diagnosis. Methods. The study included 63 HIV-infected patients with anemia of chronic disease. Assessed were the frequency of complaints and physical changes, erythrocyte indices, serum iron level, total iron-binding capacity of the blood, soluble transferrin receptor and erythropoietin markers of inflammation (ferritin, interleukin-1β, tumor necrosis factor-α, soluble receptor CD14, C-reactive protein). Comparison group consisted of a group of 35 patients with iron deficiency anemia. Results. The most frequent were complaints of weakness, fatigue and diarrhea. Hemoglobin level of the majority of patients corresponded to mild anemia. It often had a micro- or normocytic character (48.1±6.8 and 46.3±6.8% of patients, respectively), was normochromic (53.7±6.8% of patients) and hyporegenerative; in 94% of patients relative level of reticulocytes in the blood level was 0.2-1.2%; 87.3% had a reduced number of red blood cells. A negative relationship between levels of hemoglobin with erythropoietin (r=-0.5, p=0.0003) was established. Low levels of serum iron was typical for anemia of a chronic disease, as well as for iron-deficiency anemia. In patients with anemia of chronic disease revealed were significantly higher levels of soluble receptor CD14, C-reactive protein and ferritin and the relatively low level of total iron binding capacity of serum. Conclusion. Anemia of chronic disease in HIV infection is characterized by a predominance of light forms, the frequent lack of «typical for anemia» complaints; mainly micro or normocytic, normochromic types of process with low serum iron; hyporegeneration character against the backdrop of an adequate response to erythropoietin-synthesizing cells decrease in hemoglobin concentration; high levels of markers of inflammation (sCD14, C-reactive protein and ferritin) and relatively low total iron binding capacity of serum.
Kazan medical journal. 2014;95(5):769-775
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Letters to the Editor

Zemnoy poklon lyudyam v belykh khalatakh

Kazan medical journal. 2014;95(5):776
pages 776 views

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