Vol 99, No 1 (2018)

Theoretical and clinical medicine
Circulating tumor cells and their relationship with clinical and morphological characteristics of colorectal cancer
Kit O.I., Kolesnikov V.E., Tolmakh R.E., Novikova I.A., Shul’gina O.G., Komarova E.F., Demidova A.A.

Aim. To investigate the dependence of the number of circulating tumor cells in peripheral blood of colorectal cancer patients on the clinical and morphological characteristics of underlying disease.

Methods. 91 patients with verified metastatic colorectal cancer Т3-4N1-2М1 were included in the study. The average age of the patients was 61.5±1.7 years. The patients were divided into the study group (laparoscopic surgical treatment, n=44) and control group (open surgical intervention, n=47). The number of circulating tumor cells was determined in CellSearch™ system in the peripheral blood drawn before the intervention. The study of the association of attributes by constructing contingency tables consisted in calculating Pearson’s contingency coefficient c2 with Mantel-Haenszel correction for likelihood (nonparametric correction), estimating statistical significance of contingency and analyzing the tightness of the association by A. Chuprov’s mutual contingency coefficient.

Results. We found contingency of the number of circulating tumor cells with clinical and morphological parameters of patients with colorectal cancer. The relationship between potential risk factors and increase of the number of circulating tumor cells in the peripheral blood was observed in all colorectal cancer patients, regardless of the surgical intervention method. The most pronounced association of the number of circulating tumor cells in the peripheral blood of metastatic colorectal cancer patients before surgery according to the mutual contingency coefficient (K) was shown to be with present distant metastases (status M1b; K=0.63, p=0.0001) and stage T4 (K=0.56, p=0.0009).

Conclusion. The obtained results emphasize the important predictive significance of the circulating tumor cells level in peripheral blood for assessment of the potential for colorectal cancer progression.

Kazan medical journal. 2018;99(1):5-9
Neoadjuvant chemoimmunotherapy for inoperable ovarian cancer
Nerodo G.A., Zlatnik E.Y., Novikova I.A., Ardzha A.Y., Verenikina E.V., Nikitina V.P., Kravtsova O.E., Bondarenko E.S., Zolotareva E.I.

Aim. To assess the results of neoadjuvant chemoimmunotherapy for patients with inoperable ovarian cancer.

Methods. The study included 72 patients with stage IIIС-IV ovarian cancer divided into three groups: with neoadjuvant chemotherapy and with neoadjuvant chemoimmunotherapy with intramuscular and intraperitoneal interferon gamma. Direct and immediate results of the treatment were studied and compared to assess the efficacy of treatment. Besides, ploidy determination and cell cycle analysis were performed on the fresh postoperative specimens by DNA flow cytometry. Immune status was evaluated before and after neoadjuvant therapy.

Results. After neoadjuvant polychemotherapy, in the group of intramuscular interferon gamma high-volume surgery was performed in 81.8% of patients, in the group of intraperitoneal interferon gamma - in 87.5% (p ≤0.05), and in the control group (without interferon gamma) high-volume surgery was performed in 34.6% of patients. Recurrence rates were found to be 25% in the group of intraperitoneal interferon gamma (р <0.05) vs. 59.09% in the group of intramuscular interferon gamma and 76.9% in the group without interferon gamma. The study revealed a decreased number of aneuploid tumors in the group of intraperitoneal interferon gamma. The analysis of the immune system showed positive dynamics of the immune status in the groups with interferon gamma.

Conclusion. Use of interferon gamma in the complex with neoadjuvant chemotherapy improves direct results of the treatment and extends the time to recurrence; intraperitoneal and intramuscular interferon gamma is characterized by similar positive immunological changes in some cellular immunity parameters; the number of aneuploid tumors in patients with chemoimmunotherapy is lower than in the control group indicating better disease prognosis.

Kazan medical journal. 2018;99(1):10-16
Evaluation of the results of local treatment of donor site wounds in patients with deep burns
Mordyakov A.E., Charyshkin A.L., Slesareva E.V.

Aim. Evaluation of the effectiveness of donor site wounds treatment in own liquid medium in patients with deep burns.

Methods. The study included 135 patients with deep burns, who underwent split-thickness skin grafting. The average age of patients was 52.4±1.5 years. Distribution by gender: men - (65.9%) patients, women - 46 (34.1%). In the study group (n=74) treatment of donor site wounds was carried out with moisture-controlled film dressings DDB-M. In the comparison group (n=61) treatment was performed using wet-to-dry gauze dressings with a solution of iodine-containing antiseptics in combination with additional physical methods of wound drying. Evaluation of the effectiveness of treatment methods for donor site wounds was conducted by analyzing clinical and laboratory data, bacteriological, cytological, morphological studies, and statistical methods.

Results. In the structure of complications of donor site wounds in case of conventional treatment suppuration prevails - 23.7% of patients, and in case of treatment with moisture-controlled film dressings DDB-M bleeding prevails - 12.2% of patients. Epithelialization in the study group (n=74) occurred on average 2 days earlier than in the comparison group (n=61), the difference was statistically significant (U=146.0; p=0.000).

Conclusion. The treatment of wounds in own liquid medium is an effective way, as it significantly shortens the period of epithelialization; a significant disadvantage of this method is lack of haemostatic prophylaxis of bleeding from donor site wounds in postoperative period, that could worsen its course, especially in patients with severe burns.

Kazan medical journal. 2018;99(1):17-23
Influence of diuretic therapy on the features of heart rhythm variability changes in chronic heart failure patients
Alyeva K.R., Bakhshaliev A.B., Kakhramanova S.M.

Aim. To study comparative influence of furosemide and torasemide on heart rhythm variability in patients with chronic heart failure of ischemic origin.

Methods. The study included 48 patients (29 males and 19 females) with ischemic heart disease complicated by chronic heart failure, NYHA functional classes II-IV. All patients were randomized into two groups: group 1 (25 patients) received furosemide as diuretic therapy, and group 2 (23 patients) received torasemide. All patient underwent clinical examination including assessment of complaints and physical examination, laboratory and instrumental tests (electrocardiography, echocardiography, 6-minute walk test, 24 Hour Holter ECG monitoring) before and 30 days after starting diuretic therapy.

Results. Against the background of one-month diuretic therapy, positive dynamics of clinical parameters was registered in both main groups of patients receiving both furosemide and torasemide. In furosemide group deterioration of heart rhythm variability was observed. Torasemide treatment resulted in considerable improvement of vegetative regulation of heart activity.

Conclusion. Diuretic therapy with furosemide is characterized by changes of time and spectral parameters of vegetative regulation of heart rhythm towards strengthening of sympathetic and attenuation of parasympathetic influence; diuretic therapy with torasemide resulted in considerable improvement of heart rhythm variability parameters, attenuation of sympathetic and strengthening of parasympathetic influence on heart rhythm that provides additional cardioprotection in the treatment of patients with chronic heart failure of ischemic origin.

Kazan medical journal. 2018;99(1):23-29
Clinical and pathogenetic interrelation between molecular regulation of apoptosis and cell differentiation in osteoarthritis
Kabalyk M.A., Plekhova N.G., Lagureva A.V., Sunyaykin A.B.

Aim. To determine clinical and pathogenetic relationship between the levels of apoptosis and growth and differentiation regulation (growth inhibitor 1 induced by oxidative stress, growth/differentiation factor 5) in osteoarthritis.

Methods. In a rheumatology office of Vladivostok polyclinic №3 65 patients with knee osteoarthritis Kellgren grade 1-4 aged 66.5±8.0 years were examined. 25 healthy volunteers matched by sex and age without clinical and radiologic manifestations of osteoarthritis were included into control group. To measure concentration of the studied molecules in study patients’ blood, ELISA method was used.

Results. Patients with osteoarthritis compared to control group had statistically significantly increased levels of Fas, growth/differentiation factor 5 and ratio of growth/differentiation factor 5/growth inhibitor 1 induced by oxidative stress. Fas levels were significantly lower in late stages 2-4 of osteoarthritis compared to stages 1 and 2. Growth/differentiation factor 5 level was lower in patients with stage 3-4 of osteoarthritis compared to stages 1 and 2. As radiologic signs of osteoarthritis progressed, decrease of the ratio of growth/differentiation factor 5/growth inhibitor 1 induced by oxidative stress, was registered which was significantly lower in stages 2 and 3 compared to stage 1.

Conclusion. Extrinsic pathway of apoptosis plays a big role in forming pain syndrome in osteoarthritis, and its maintenance is provided by other mechanisms which include influence of oxidative stress via inhibition of cell cycle mediated by growth inhibitor 1 induced by oxidative stress, reduced involvement of growth/differentiation factor 5 in differentiation processes and regulation of protein synthesis of extracellular cartilaginous tissue matrix.

Kazan medical journal. 2018;99(1):30-36
Mechanisms of illegal aggressive behavior of women suffering from schizophrenia
Kekelidze Z.I., Kachaeva M.A., Khamitov R.R., Afzaletdinova D.K.

Aim. To establish comparative clinical and psychopathological and social factors leading to realization of intrafamilial and extrafamilial aggressive actions of females suffering from schizophrenia when comparing the mechanisms of illegal actions.

Methods. The article presents the results of the study of 91 female patients diagnosed with schizophrenia according to the International Classification of Diseases, 10th revision, (F20.0) of continuous and episodic with progressive deficit type of course, who committed aggressive socially dangerous acts and are admitted for involuntary treatment to Kazan psychiatric hospital of specialized type with intensive supervision. Two groups were identified: group 1 included 57 patients committed aggressive criminal acts in the family, and group 2 included 34 patients committed criminal acts against persons outside the family. A comparison was performed between two basic scientific concepts regarding the reasons and conditions of illegal acts committed by mentally ill persons. Statistical significance of the differences between the compared data was determined (using Fisher's angular transformation criterion and Mann-Whitney test).

Results. Comparative study of the analysis concepts of illegal behavior in females suffering from schizophrenia demonstrated that the results turned out to be more detailed when using the concept of psychopathological mechanisms. So, in the productive psychotic mechanism imperative hallucinations and automatisms were noted predominantly in women from group 1 - in 59.5% (p1 <0.01), and in group 2 - in 28%. Productive psychotic mechanism with delusion determined in 68% of cases in group 2 significantly predominated by prevalence over group 1 (p1 <0.01), where it was revealed at commitment of criminal acts in 38.1% of patients. Delusional revenge was noted more often in women from group 2 - in 28% (p1 <0.05), than in group 1 - 7.1%.

Conclusion. Presence of mental disorder in the form of schizophrenia determines realization of aggressive illegal behavior not always by strictly psychopathological mechanism; in this case, illegal acts of the patients committed by negative personal mechanism are close to violation of law motives of women ruled sane.

Kazan medical journal. 2018;99(1):36-41
Experimental medicine
Morphological signs of the intravital contraction (retraction) of thrombotic emboli
Khismatullin R.R., Shakirova A.Z., Peshkova A.D., Litvinov R.I.

Aim. To establish whether contraction (retraction) of thrombi and thrombotic emboli occurs in vivo using structural signs of blood clot compression, such as compressive deformation of erythrocytes and redistribution of fibrin on the surface of a clot.

Methods. Three postmortem pulmonary thrombotic emboli were examined by scanning electron microscopy and light microscopy after staining with hematoxylin and eosin as well as with Mallory’s method.

Results. In 2 studied pulmonary emboli, extracted 7 and 15 hours after patients’ death, polyhedral erythrocytes (polyhedrocytes) were revealed that were formed as a result of mechanical deformation under the action of contractile forces generated by activated platelets. In addition, the uneven distribution of fibrin within the emboli was found with displacement of fibrin to the periphery of the emboli, which is characteristic for contracted blood clot. In the first and the «oldest» clot extracted 38 hours after the patient’s death, the described contraction signs were absent, which was likely related to the postmortem autolysis or intravital pathological impairment of contraction.

Conclusion. Thrombotic emboli ex vivo have morphological signs of contraction, suggesting intravital compression of the primary thrombi and/or thrombotic emboli, which might be an important pathogenetic mechanism for modulation of impaired blood flow at the sites of thrombotic occlusion of a vessel; the presence or absence of compressed erythrocytes inside and predominant location of fibrin on the periphery of a thrombus or embolus can potentially serve as additional pathomorphological criteria of death coming prescription.

Kazan medical journal. 2018;99(1):42-47
Role of O6-methylguanine-DNA methyltransferase and p53 in response of neuroblastoma cells to an alkylating agent temozolomide
Khusnutdinov R.R., Boychuk S.V.

Aim. To study the role of p53 and O6-methylguanine-DNA methyltransferase in sensitivity of neuroblastoma cells to temozolomide.

Methods. The study was performed on SK.N.SH neuroblastoma cell line cultured in DMEM medium supplemented with fetal bovine serum and antibiotics penicillin-streptomycin in the standard conditions (37°C and 5% СО2). The cells were cultured with an alkylating agent temozolomide for 48-72 h. For particular experiments, cells were pre-cultured for 2 hours with O6-benzylguanine (a competitive inhibitor of O6-methylguanine-DNA methyltransferase) or nutlin-3a (reactivator of p53). Proliferative activity was evaluated by using a system of multiparametric analysis of cell cultures (RTCA iCELLigence) as well as MTS-based colorimetric assay. Protein expression was measured by Western blotting by using the corresponding monoclonal antibodies.

Results. Reactivation of p53 protein substantially inhibited proliferation rate of SK.N.SH cells. Cytotoxic effect of a medication was more significant compared to temozolomide considered as an agent of choice for chemotherapy for patients with glioblastoma multiform or neuroblastoma. Inhibition of O6-methylguanine-DNA methyltransferase also enhanced the cytotoxic effect of temozolomide, however, cytotoxic effect of a chemotherapeutic agent was less expressed compared to temozolomide, along with p53 reactivation.

Conclusion. Functional state of p53 protein in tumor cells is a more important prognostic marker of neuroblastoma cells’ sensitivity to an alkylating agent temozolomide compared to O6-methylguanine-DNA methyltransferase expression; in addition, reactivation of p53 protein induces the decrease of proliferation rate of neuroblastoma SK.N.SH cells and their death via apoptosis.

Kazan medical journal. 2018;99(1):47-53
Morphological characteristics of experimental ischemic wound healing after application of autoand hetero-fibroblasts and dermal equivalent
Shapovalova E.Y., Boyko T.A., Baranovskiy Y.G., Lugin I.A.

Aim. To study morphological structure, collagen synthesis and angiogenesis in biopsy samples of newly formed epidermis and derm on day 19 of their repair in experimental ischemic wound after application of auto- and hetero-fibroblasts as well as after transplantation of dermal equivalent with hetero-fibroblasts.

Methods. The study was performed on 28 mature C57/B1 white mice younger than 1 year. Around and into the bed of surgical skin wound in the scapular region, 0.4 ml of suspension of fibroblasts and 1.33 million cells of dermal equivalent were injected. Biopsy sample was embedded in paraffin and was stained with hematoxylin and eosin and by Weigert-Van Gieson.

Results. Most importantly, regenerative histogenesis is affected by introduction of auto-fibroblasts, when the greatest thickness of the epidermis is registered and angiogenesis and collagen formation are most active. At the same time, the most differentiated epidermis is observed after transplantation into the wound of dermal equivalent with hetero-bifroblasts.

Conclusion. The beneficial effect of dermal equivalent with hetero-bifroblasts differs from the effect of auto-fibroblast suspension by only a few percent: epidermal thickness by 4.29%, the area of collagen fibers by 2.66%, the area of blood vessels by 4.04%, that makes such differences unreliable.

Kazan medical journal. 2018;99(1):53-59
Determination of the concentration of circulating immune complexes, immunoglobulin E and G and histamine in the blood and lymph in experimental anaphylactic shock and Arthus phenomenon
Alieva T.R.

Aim. Study of the concentration changes of circulating immune complexes, immunoglobulin E and G and histamine in the blood and lymph in experimental anaphylactic shock and Arthus phenomenon.

Methods. Experiments were conducted on 27 chinchilla rabbits in two series. The studied levels of circulating immune complexes, histamine and immunoglobulin E and G in the blood and lymph of intact animals were used as a control.

Results. The level of histamine in anaphylactic shock increases by 3.8 times, while the level of immunoglobulin E and G increases by 14.7 and 3.5 times compared to intact animals, and the concentration of circulating immune complexes increases to 23 mmol/l during the same period. In Arthus phenomenon the level of immunoglobulin E in the blood increases by 1.3 times, and immunoglobulin G level increases by 4.3 times. The concentration of circulating immune complexes increases by 11.8 times, histamine level raises by 3.5 times compared to intact animals.

Conclusion. The concentration of circulating immune complexes increases both in anaphylactic shock and in Arthus phenomenon; immunoglobulin levels change in different ways: in anaphylactic shock an increase of immunoglobulin E level and decrease of immunoglobulin G level occur, while in Arthus phenomenon, to the contrary, an increase of immunoglobulin G level and decrease of immunoglobulin E level are observed; histamine level increases both in anaphylactic shock and in Arthus phenomenon, however, more significantly in anaphylactic shock; in both allergic reactions the role of circulating immune complexes in the increase of histamine concentration is not excluded, but apparently, the key role is given to immunoglobulin E.

Kazan medical journal. 2018;99(1):59-63
Increase of anticoagulant and fibrinolytic activity of rat blood plasma when using products of velvet antler industry
Blazhko A.A., Shakhmatov I.I., Zharikov A.Y., Kiselyov V.I.

Aim. To evaluate the reaction of hemostatic system in rats on various duration of the intake of concentrated product containing blood and histolysate of Siberian stag reproductive organs, and to exclude the possible adaptive effect of additives (glucose, ascorbinic acid, fruit essences), contained in the used concentrate, on hemostatic system.

Methods. The study included 50 mature male Wistar rats. Three groups of experimental animals, including 10 rats each, received the concentrate containing blood and histolysate of the Siberian stag reproductive organs in the dose of 4.5 ml per day for 7, 14 and 30 days. Parameters obtained from the experimental animals were compared to those from intact rats and control group, receiving only additives, contained in the used concentrate.

Results. On day 7 of concentrate administration, the hemostatic parameters did not differ from those of intact rats. After 14 days of concentrate administration, decrease of fibrinogen concentration in blood and increase of anticoagulant activity of blood plasma were observed. On day 30 of concentrate intake, in addition to the earlier revealed changes in hemostatic system, hypocoagulation in the intrinsic pathway of plasma hemostasis activation and also increase of fibrinolytic activity of blood plasma were registered. Upon the expiration of 30 days of administration of additives, contained in the studied product, hemostatic parameters of the animals from the control group did not differ from those of intact rats.

Conclusion. Increase of adaptation of hemostatic system when taking the studied concentrate apparently involves increase of anticoagulant and fibrinolytic activity of rat blood plasma and reduction of fibrinogen concentration in the blood; the active component providing adaptive changes in the hemostatic system is the complex of biologically active substances contained in the blood and histolysate of the Siberian stag reproductive organs.

Kazan medical journal. 2018;99(1):64-69
Prevention and management of inadvertent perioparatve hypothermia
Akhmetzyanov F.S., Shaymardanov I.V., Pasheyev A.V., Sayetgarayev A.K., Muftakhutdinova G.S., Sadykov K.K., Khasanov A.F., Egorov V.I.

Human body central temperature is an important monitored value for anesthesiology and intensive care practice. Present anesthetic agents influence on the central temperature regulation and lead to its decrease in the perioperative period. Inadvertent perioperative hypothermia accompanies various surgeries with general and regional anaesthesia. It considerably increases the risk of cardiac and infectious postoperative complications, and against its background blood loss and necessity for blood transfusions also increase. Patients with hypothermia wake up slower and the postoperative shivering may often occur. Perioperative hypothermia increases the length of hospital stay and the nosocomial mortality. In this regard, prevention of inadvertent perioperative hypothermia is an important part of anaesthesia assistance in all fields of surgery. Maintenance of normal temperature during the surgery is an important component of all programs of patient’s early postoperative activation.

Kazan medical journal. 2018;99(1):70-78
Features of obesity treatment in patients with gastroesophageal reflux disease
Andreeva E.I.

In the past few decades, the worldwide prevalence of such nosological forms as gastroesophageal reflux disease and obesity has been increasing. The combination of these pathologies is more often observed in patients who have nutrition and lifestyle issues, as well as genetic predisposition to these nosologies. Patients with obesity are noted to have predisposition to diaphragmatic hernias and mechanical damage of gastroesophageal junction, which occurs against the background of increased intragastric pressure and increased pressure gradient between the stomach and esophagus, as well as due to extension of the proximal part of the stomach. One of the basic pathogenetic moments of gastroesophageal reflux disease is spontaneous relaxation of the lower esophageal sphincter. According to recent studies, in obesity the frequency of postprandial spontaneous relaxation of the lower esophageal sphincter increases even in the absence of diaphragmatic hernia, non-erosive gastroesophageal reflux disease and reflux esophagitis. The variety of metabolic disorders observed in these patients requires a comprehensive approach to treatment, aimed both at effective reduction of the acid-peptic factor and at correction of excessive body weight. Both non-pharmacological and pharmacological methods are distinguished among the main treatment directions for both components of this combined pathology. An important role in therapy is given to activities that contribute to the maintenance of healthy lifestyle: smoking cessation, weight loss, dietary nutrition, health-improving physical culture. Among medications for patients with gastroesophageal reflux disease and obesity, which allow achieving an optimal acid-reducing effect, specific attention is assigned to a group of proton pump inhibitors (H+/K+-ATPase inhibitors), which have a lower affinity for hepatic cytochrome P450 enzyme system, do not affect its activity and do not clinically significantly cross-react with other drugs.

Kazan medical journal. 2018;99(1):78-84
Interstitial cystitis: painful bladder syndrome
Sholan R.F., Garaev G.S., Nasrullaeva G.M.

Interstitial cystitis, or painful bladder syndrome, is a chronic inflammatory disease of a bladder of unknown etiology. It negatively affects the quality of life, causes depressive disorders, anxiety, and sexual dysfunction. Despite numerous studies, the etiology of interstitial cystitis is still unclear and it’s considered as painful bladder syndrome with multifactorial origin. According to the US National Health and Nutrition Examination Survey, 470/100 000 people (60/100 000 men, 850/100 000 women) are diagnosed with interstitial cystitis. Diagnosis of the disease is difficult and is substantially based on clinical symptoms. Pelvic pain, urinary urgency, frequency and nocturia are the basic complaints in this pathology. The diagnosis requires exclusion of diseases with similar manifestations. So interstitial cystitis is frequently misdiagnosed as urinary tract infection, overactive bladder, urethral obstruction or diverticulosis, chronic prostatitis, bladder cancer, vulvodynia, endometriosis, and chronic pelvic pain. Etiopathogenesis of the disease is uncertain, which makes etiologic treatment impossible. Currently scientific discussions on the causes of disease continue as well as different treatment regimens are offered, but are often ineffective, palliative and temporary. The treatment for intersticial cystitis should focus on restoring normal bladder function, prevention of relapse of symptoms and improvement of patients’ quality of life. The literature review presents current view on the terminology, epidemiology, diagnosis and treatment of interstitial cystitis.

Kazan medical journal. 2018;99(1):84-91
Social hygiene and healthcare management
Prognosis of medical and economic efficiency of a patient-oriented program implementation aimed at formation of adherenceto drug therapy among rural population
Kitaeva E.A., Suetina T.A., Kitaev M.A., Bakirova E.A., Salyakhova L.Y., Vafin A.Y.

Aim. Development and implementation of novel organizational management technologies of medical care aimed at formation of adherence to drug therapy in patients from rural areas and calculation of medical and economic efficiency of implementation of this project.

Methods. The study subject was the population of Rybnaya Sloboda district of the Republic of Tatarstan. Patient recruitment into the groups was conducted in the polyclinic of Rybnaya Sloboda central regional hospital. The duration of the study was 6 months for each of two groups with further follow-up and evaluation of adherence to therapy for 2 months.

Results. Annually stroke affects 5.6 to 6.6 million of people around the world, 35% of whom die in the acute period. Recently, serious rejuvenation of cardiovascular disorders has been observed. The main reason for such trend is low patients’ compliance to drug therapy. And patients’ compliance itself allows significantly decreasing the risk of cardiovascular complications. The article discussed the issues of low compliance to drug therapy, presents the methods of its formation in patients from rural area. The examples of foreign and Russian experience of increasing patients’ compliance to drug therapy are described and the key intervention points for patients are determined. On the basis of conducted analysis, implementation was developed and suggested for patient-oriented program aimed at formation of adherence to drug therapy of rural population. Also, the authors performed evaluation of medical and economic efficiency of implementation of a patient-oriented program aimed at formation of adherence to drug therapy of rural population (assessment of expenditures for medications, hospital stay, incapacity related to the main disease; evaluation of expenditures for prevention of complications and disability).

Conclusion. Effective organization of prophylactic activity is of great importance for prevention of cardiovascular disease complications and directly affects population’s economic well being.

Kazan medical journal. 2018;99(1):92-100
Evaluation of medical records maintenance quality in dental medical organizations of Kazan
Lapina A.K., Saleev R.A., Vagner V.D., Saleeva G.T., Smirnova L.E., Mindubaeva F.F.

Aim. Improvement of the quality control of dental medical organizations when diagnosing dentoalveolar anomalies and deformities.

Methods. A retrospective analysis of an orthodontic patient’s medical record maintenance at the dental clinics of Kazan.

Results. Only 30.7% of all the verified documentation were established to be most thoroughly and correctly filled. Information about the obligatory medical insurance policy was indicated only in 2 cards out of all the verified documentation. In all orthodontic patient medical records the fringe benefit category code was absent. The name of the insurance organization in which a patient was unsured, was available only in 2.3% of the cards. Patient’s passport data were available only in 14 (15.9%) cards, and the type of payment for services was registered only in 38 (43.2%). The diagnosis established by a referring medical organization was indicated only in 7 (8%) of the records. When examining the dental rows of patients, their dimensions and apical bases of the jaws, the shape of the dentition were indicated in 40.9% of the documentation. The contact of adjacent teeth was described in 36.4% of all cases, presence of diastema between the upper jaw incisors was represented in 30.7% of the medical charts of orthodontic patients. The diastema between the lower jaw incisors was reflected in 25 (28.4%) medical charts of orthodontic patients. Based on the doctor’s notes in the medical records, it is difficult to understand whether the whole necessary list of diagnostic measures had been performed to the patient in order to confirm this or that orthodontic pathology. Such filling of the medical chart of orthodontic patient at times makes the experts doubt in the correctness of diagnosis of a certain patient.

Conclusion. Doctors-orthodontists do not pay enough attention to the collection of anamnesis of the disease, evaluation of the nature of complaints, as well as use of basic and additional methods of patient examination.

Kazan medical journal. 2018;99(1):101-109
Health-preserving space in medical educational institutions
Gatiyatullina L.L.

Currently the issue of health-preserving educational technologies and programs and their implementation in educational process of higher school is actively discussed. Health-preserving technologies in the educational process are a complex of methods, tools and conditions facilitating at maximum preserving and improving physical, mental and moral health of the subjects of educational process. Analysis of the literature dedicated to the problem of implementation of health-preserving space in medical educational organizations, was performed. Its development path promoting preservation and improvement of physical, psychoemotional and social and moral students’ health, is described. Role of health-preserving space in formation of students’ healthy behavior is discussed. The result of formation of health-preserving educational space is the use of health-preserving educational technologies, teaching the students the skills of individual achievement of a definite level of health and education, physical and physiological readiness, and ability to solve personal and professional problems. Significance of the formation of health-preserving space and training health-preserving technologies is determined by the specificity of students’ future profession. Development in this direction is high-priority for pedagogic and educative work with the students, it will promote robust professional formation of a future medical professional. When creating health-preserving space, health-preserving technologies have to be integrated in educational and pedagogic process. The literature review showed that at the present stage novel understanding is formed about the role of health-preserving space state in medical educational organizations and students’ lifestyle in preserving health. Various points of view on an issue of forming students’ health-preserving behavior are presented.

Kazan medical journal. 2018;99(1):110-116
Analytical health evaluation of young age persons (18-29 years) in the city of Novosibirsk
Pogodina V.A., Babenko A.I., Babenko E.A., Khaiatova Z.B.

Aim. Analytical evaluation of physical state of the body and health in 18-29-year-olds according to medical records from 2015-2016 in Novosibirsk.

Methods. With the use of sampling method with representativeness, randomization, stratometric selection, and analytical discussion, the indices of physical development, characteristics of a disease, and health groups were studied. Material of the study was information extracted from the official statistical registration forms (No. 025/u-04; No. 025-12/u. No. 131/u) of 250 patients aged 18-29 years.

Results. Accepted in the Russian Federation standard indicators of somatotype, blood pressure, heart rate and respiratory rate were revealed in 34.4 to 78.4%. Adults with asthenic and hypersthenic somatotype constituted 42.8 and 22.9%, respectively. The ratio of a cohort with bradycardia was 8.4%, and with tachycardia - 21.6%. The proportion of persons with low and high blood pressure was 21.6%. No patients with bradypnea were registered, and in 21.6% of the sample tachypnea was observed. Among adults aged 18-29 years, noninflammatory disorders of female genital organs, diseases of male genital organs, and acute respiratory infections of the upper respiratory tract were the most spread. Only in 19.2-21.6% the cohort had no disorders. However, 48.4-50.0% of persons had a mild chronic pathology and needed follow-up monitoring and further evaluation. 30.0-50.0% of population had an acute disease of moderate severity or high total risk of developing a chronic disease and required follow-ups.

Conclusion. The revealed deviations from the Russian age health norms can become the basis for the development of the standard variants for comprehensive health assessment of the adult cohort by age and region.

Kazan medical journal. 2018;99(1):116-121
Inter-regional differences in the rate and structure of the causes of primary disability among the population of rural areas of Azerbaijan
Sadykhzade L.N., Agaeva K.F.

Aim. Evaluation of the differences in the rate of primary disability among the population of rural areas of Azerbaijan in 2014, as well as the structure of its cuses.

Methods. The study was conducted in five administrative regions of republican subordination in Azerbaijan (Absheron, Sheki, Gakh, Ismayilli, Agdash). The choice was based on that by the Ministry of Healthcare of Azerbaijan Republic they were included in the groups of pilot regions for approbation of reforming strategy for rural healthcare system. Statistical processing of data was performed with the use of analysis of qualitative signs, mean error and 95% confidence intervals were determined (t=1.96). Correlation between regional data was evaluated by Pearson and Spearman method. Interregional differences of parameters were assessed by χ2 criteria using Yates's correction.

Results. Primary disability rate was studied (per 10 000 population). Maximal and minimum rates of primary disability among children were found in Ismayilli and Gakh regions, respectively (74.5±6.2 and 28.5±5.1 per 10 000 children below 14 years of age). In comparison with Gakh region, significantly higher rate (р ≤0.05) of primary disability among children younger than 14 years was registered in Sheki, Ismayilli and Agdash regions. Use of correlation analysis by Pearson method allowed determining statistically significant correlation only between the rate of primary disability among adults and physician supply (r=0.96; t=5.9), and also infant mortality rate (r=0.86; t=2.9).

Conclusion. Interregional differences are more pronounced in the rate of primary disability both among children and adult population with similar nosological structure of causes of disability; primary disability rate among adults has a significant correlation with social and economic characteristics of the regions.

Kazan medical journal. 2018;99(1):121-126
Correction of female contraceptive behavior and its role in preventing undesired pregnancy
Gabibova K.G.

Aim. Finding approaches for the correction of female contraceptive behavior and assessment of its role in the prevention of undesired pregnancy.

Methods. In three city women's consultation clinics of Baku and adjacent schools and kindergartens a survey of women was conducted. International Women’s Health Questionnaire was used. The response comprised 1577 (39.4±0.8%) questionnaires. Outreach program for women on the issues of contraception was provided. It had lasted for 23-27 months. At the end, necessary data were obtained from 946 women.

Results. At the beginning of program, 48.1±1.6% of women used no contraception, only 11.8±1.0% of women constantly used it. As a result, among 4427 pregnancies the number of undesired pregnancies totaled 2092, 1901 of them resulted in abortion. As a result of organizational and informational outreach, the number of women not using contraception decreased to 15.5±1.2% (p <0.001), and the number of women using contraception on a permanent basis increased to 50.2±1.6% (p <0.001). Achievement of such positive results was facilitated by the fact that during 23-27 months the number of women using contraception on a permanent basis has significantly increased. Therefore, contraception plays a vital role in effective family planning, and, when used correctly and consistently, it prevents undesired pregnancies and related to them abortions. However, lack of awareness of the issues of contraception is the main reason for low level of using contraception. As a result, prevalence of undesired pregnancies per 1 woman during 23-27 months decreased from 2.16 to 0.19 cases (p <0.001).

Conclusion. Available outreach and regular contacts with women for a fixed period increased their demand of contraception, which significantly reduced the risk of undesired pregnancy and related to it rate of abortions.

Kazan medical journal. 2018;99(1):127-131
Study of factors affecting attitude towards people with mental illness in Azerbaijan
Rasulov A.R.

Aim. To determine the factors that form attitude towards persons with severe mental disorders, as well as to establish a correlation between these factors and socio-demographic variables.

Methods. Cross-sectional study was conducted among 1000 respondents in five regions of the country. The questionnaire included nine statements designed to identify different aspects concerning the relation of society towards people with mental disorders. The interviews were conducted by specially trained volunteers living in the capital and regions of the country. All interviewers were instructed about the objectives of the study and procedure of the survey and 1100 printed questionnaires were distributed. As a result, 996 completed questionnaires were collected, thus the response to the survey comprised 90.5%, i.e. the number of study participants was consistent with the planned sample size.

Results. The study established three-factor structure of attitude towards people with mental disorders. Older age and personal acquaintance with a patient was associated with lower degree of social distance, while female gender was associated with greater degree of social threat perception. The tolerant attitude positively correlated with marital status and familiarity with patients, and negatively with the presence of mental illness in the family. The results of the multivariate linear regression suggest that social distancing does not depend on gender, education, marital status and place of residence of the respondents. However, older persons are more likely to recognize the fact that persons with mental disorders are unable to adapt to society and to fulfill social functions. In addition, personal experience of dealing with patients is associated with lower level of social distancing.

Conclusion. The three-factor structure allows better understanding of various aspects of stigmatization of persons with mental disorders.

Kazan medical journal. 2018;99(1):131-139
Clinical observations
Surgical removal of atrial septal defect occlusion device and mitral valve replacement in a 39-year-old female patient with infective endocarditis
Zotov A.S., Borisov D.V., Klypa T.V., Vachev S.A.
Atrial septal defects represent the second most frequent congenital heart disease after ventricular septal defects. Transcatheter closure of an atrial septal defect is usually performed following strict indications on patients with significant left-to-right shunt. Infective endocarditis after transcatheter implantation of atrial septal defect occluder is an extremely rare complication. We report a case of infective endocarditis of the mitral valve (with severe mitral valve insufficiency) in a 39-year-old female patient 13 years after transcatheter closure of an atrial septal defect. Complex prophylactic antibiotic coverage was performed prior to surgical intervention. Surgical removal of atrial septal defect occluder, mitral valve replacement, atrial septal defect closure and left atrial appendage resection were performed. Postoperative course was uneventful.
Kazan medical journal. 2018;99(1):140-143
Case of uterine scar rupture in the second trimester of pregnancy after preceding caesarean section
Kurmanbaev T.E., Tukhvatullina L.M., Khayrullina E.A., Gataullina N.M., Zhirnov V.A.

Uterine rupture is one of the rare and severe complications of pregnancy and childbirth. It most often occurs in the third trimester however there are publications on cases of uterine rupture in the second trimester. In the available Russian literature we were unable to find any publications regarding uterine scar rupture in the second trimester after preceding caesarean section; available publications focus on uterine scar rupture after preceding myomectomy. Prevalence of caesarean section has recently increased dramatically both in the world and in Russia, besides the data about possibility of pregnancy prolongation in case of uterine scar rupture appeared. It encouraged us to present clinical observation. It demonstrates that uterine scar rupture in the early stages of pregnancy is paucisymptomatic and is often considered as a threatening miscarriage. It is necessary to remember that threatening miscarriage is usually characterized by shortening and softening of the cervix which are not observed in case of threatening or accomplished uterine scar rupture. As such factors, as the time of uterine rupture symptoms occurence, gestational age, localization of placenta, absence of placenta rotation, fetal viability, size of the uterine scar and the characteristics of scar rupture are the main predictors for the decision of pregnancy prolongation in case of uterine scar rupture, so the early diagnosis of such condition is of great importance.

Kazan medical journal. 2018;99(1):144-148
Recurrence of fungal keratitis in corneal transplant
Poltanova T.I., Belousova N.Y.

The article presents a clinical case of fungal keratitis in corneal transplant. A patient 4 months after penetrating keratoplasty performed for progressive corneal ulcer, was diagnosed with recurrence of fungal keratitis. Repetitive penetrating keratoplasty and subsequent anti-inflammatory therapy were performed, but 3 months later white infiltrate with distinct borders appeared in the center of corneal transplant that required removal. Laboratory investigation of the removed fragment revealed Fusarium mycelium; antimycotic treatment with amphotericin B 0.2% topically and intraconazole orally was administered for 3 weeks. In a month after the treatment visual function remained equal to correct light perception, corneal transplant was totally opacified without edema, and corneal defects re-epithelialized. Ophthalmologic examination in 2-3 months showed absence of ocular pain, smooth corneal surface without epithelial defects and corneal transplant opacity. Laboratory diagnostics is necessary in case of fungal infection suspicion. During penetrating keratoplasty for fungal corneal disease, corneal infiltrate has to be removed within intact corneal tissue. Fungal corneal infection recurrence in corneal transplant occurs at the donor-recipient interface.

Kazan medical journal. 2018;99(1):148-150
Clinical experiences
Insular epilepsy etiology: clinical manifestation and management tactics for cerebral cavernous angiomas
Khachatryan R.G., Odintsova G.V., Don O.A., Kim A.V., Telegina A.A., Ivanov A.Y., Ivanova N.E., Khachatryan V.A.

Insular epilepsy is currently of special interest for world epileptology. Many authors including W. Penfield and H. Jasper, suggested the relation between unsuccessful temporal resection and undiagnosed epileptic focus localization in insula. Despite increased interest to insular epilepsy, the data on etiologic structure remain sparse. The current paper presents literature review of etiologic role of cavernous angiomas in the origin of insular epilepsy and dissects management tactics on a clinical example. Literature search was performed in Web of Science and «Russian Science Citation Index» databases using keywords «insular epilepsy» (in English and Russian). Using a clinical example, features of manifestation and diagnosis of insular epilepsy are discussed. The international and national data on the morphological structure, localization and features of manifestations of cerebral cavernous angiomas are given. Epilepsy caused by cavernous angiomas constitute 0.4-0.9% in the general structure of the disease, and their ratio increases in the structure of pharmacoresistant forms. Management tactics for the patients with insular epilepsy was analyzed with the use of International League Against Epilepsy guidelines on cavernoma-related epilepsy (2013). Conclusion is made that solitary seizure in epilepsy onset is an indication for magnetic resonance imaging of the brain to exclude structural pathology. High-field magnetic resonance imaging according to epilepsy program is preferable. With no pathological signs on magnetic resonance imaging scans and clinical signs of vascular pathology, magnetic resonance angiography is helpful to exclude vascular malformations. Early microsurgical removal of cavernous angioma as an etiological substrate of epilepsy decreases the risk of pharmacoresistant epilepsy.

Kazan medical journal. 2018;99(1):151-157
Development of a hyaline cartilage thickness map of a normal knee joint and in knee varus and valgus deformity
Ayrapetov G.A., Vorotnikov A.A., Konovalov E.A.

Aim. Estimation of the average thickness of hyaline cartilage on the basis of magnetic resonance imaging for its further evaluation in standard radiography of the normal knee joint.

Methods. The study included 66 magnetic resonance imaging scans of healthy knee joints (30 right and 36 left joints) from 32 females and 34 males aged 35 to 59 years (mean age 47±8.1 years) with different limb axis deviation. All scans were processed manually using Syngo fastView programs to create a 3D model of the distal femoral epiphysis and the proximal tibial epiphysis, and also to differentiate between cartilage tissue and bone. The next step was measurement of hyaline cartilage thickness on the created models made at intervals of 2 mm to create a «thickness map» which later would make it possible to estimate the cartilage thickness on the basis of standard knee radiograph.

Results. The hyaline cartilage thickness varies depending on the sex and limb axis deformation. Thus, the largest thickness of cartilaginous tissue was observed on the articular surface of the femur in males 1.5-2 cm above the attachment site of the anterior cruciate ligament, and the average thickness on the femur was 1.90±0.425 mm. The largest thickness of the cartilage on the articular surface of the tibia in males was observed in the lateral side, and the average thickness was 1.64±0.434 mm. The cartilage thickness in the medial joint was significantly less in varus deformity than in valgus deformity.

Conclusion. The hyaline cartilage «thickness map» of the knee joint allows assessing its state by standard radiographs without performing magnetic resonance imaging; modification of hyaline cartilage «thickness map» in pathology will improve the treatment results for local defects and more reliably perform preoperative planning for needed knee replacement.

Kazan medical journal. 2018;99(1):157-161
Microbiological study of root canal content in dynamics of treatment of destructive forms of periodontitis
Kogina E.N.

Aim. Assessment of the efficacy of complex endodontic treatment based on microbiological study of dental root canal content.

Methods. 92 patients with destructive forms of chronic periodontitis aged 25-35 years, without endodontic intervention in the anamnesis, underwent endodontic treatment. Depending on the conducted treatment all patients were divided into two groups: in group 1 complex treatment was performed on 52 teeth based on our developed scheme, group 2 underwent treatment of 40 teeth with the use of standard treatment method. The microbiological study of root canal content was conducted before treatment and was repeated before sealing with permanent sealing material.

Results. The microbiological study of root canal content before treatment was characterized by significant variety of microbial flora, high prevalence of bacterial and fungal flora, its content was 4-5.8 lg CFU/ml. The most aggressive facultative anaerobic Gram-negative and Gram-positive bacteria were observed: Prevotella intermedia, Fusobacterium, Actinomyces spp. The repeated microbiological study after complex endodontic and standard treatment of destructive forms of periodontitis demonstrated reduction of the quantity of bacteria in root canal. The developed treatment scheme turned out to be more effective compared to the standard method. In root canals only some species were found, and in isolated cases Streptococcus intermedius, Streptococcus sangius, Enterococcus spp. were isolated in extremely small quantities, not more than 3.0 lg CFU/ml (103 CFU/ml).

Conclusion. Use of the complex endodontic and standard treatment of destructive forms of periodontitis resulted in the decrease of bacterial content and variety of species in root canal; higher microbiological efficacy was demonstrated for the suggested complex treatment method compared to the standard method.

Kazan medical journal. 2018;99(1):161-166
Possibility of predicting the efficiency of soft tissue sarcoma treatment on the basis of features of their immunological microenvironment
Zlatnik E.Y., Novikova I.A., Nepomnyashchaya E.M., Selyutina O.N., Ausheva T.V., Aliev T.A., Vashchenko L.N., Ul'yanova E.P., Mashchenko N.M.

Aim. To study the possibility of using the evaluation of local cellular immunity factors for predicting the efficiency of soft tissue sarcoma treatment.

Methods. The study included 38 patients with soft tissue sarcoma: 22 with primary and 16 with recurrent tumors, admitted for surgical treatment in 2014-2016. In all patients, the intraoperative tumor tissue samples, peritumoral zone and relatively intact tissue samples corresponding to the resection lines (a total of 114 samples) were studied to assess the local immunity indices. The tissue samples were homogenized, lymphocyte subsets were detected with a flow cytometer.

Results. Characteristics of immunological lymphocytic microenvironment of soft tissue sarcomas were studied in connection with the clinical effect of complex treatment of patients. In primary sarcomas, event-free survival at over 12 months after the surgery was related to higher level of NK-cells in tumor tissue and higher level of NKT-lymphocytes in peritumoral zone and tumor, as well as lower Tregs level than in patients with event-free survival for less than 12 months. In recurrent sarcomas, poor event-free survival was associated with high level of DN-cells in the tumor and peritumoral zone/tumor ratio for CD3+ lymphocytes. All the detected differences were statistically significant (p <0.05).

Conclusion. The clinical effect of complex treatment of soft tissue sarcomas is related to the initial state of immunological microenvironment of the tumor; some indicators of local cellular immunity can be regarded to as prognostic factors different for primary and recurrent sarcomas.

Kazan medical journal. 2018;99(1):167-173
Cochrane Review Summaries
Cerebrolysin for acute ischaemic stroke

Вопрос обзора. Есть ли какая-либо польза от использования церебролизина при лечении людей с острым ишемическим инсультом, и есть ли какие-либо риски?

Актуальность. Церебролизин, являющийся смесью, получаемой из ткани головного мозга свиньи, широко используется в России, Китае и других азиатских странах и странах постсоветского пространства. Мы провели оценку данных рандомизированных контролируемых испытаний (РКИ), исследующих церебролизин у людей с острым ишемическим инсультом.

Характеристика исследований. В этот обзор включены шесть рандомизированных контролируемых испытаний с общим числом участников 1501, в которых сравнили церебролизин с плацебо (неактивное лекарство), использованные в дополнение к стандартной терапии, в том числе к тромболизису. Три из них были крупными многоцентровыми исследованиями, два были небольшими по размеру и были признаны исследованиями неясного качества, и в одном не было числовых результатов.

Основные результаты. Доказательства актуальны по июнь 2016 г. Этот обзор, включающий шесть клинических испытаний с вовлечением 1501 участника, показал отсутствие пользы от использования церебролизина по снижению смертности при остром ишемическом инсульте. Не было разницы в общем числе людей с неблагоприятными событиями, но существуют опасения, что церебролизин может увеличить риск развития нефатальных серьёзных неблагоприятных событий по сравнению с плацебо.

Качество доказательств. Лекарство (церебролизин) и методология большинства включённых испытаний были предоставлены производителем церебролизина, создавая вероятный конфликт интересов. В настоящее время существуют доказательства среднего (умеренного) качества, позволяющие предполагать, что церебролизин работает не лучше, чем плацебо в отношении смерти от всех причин, когда он назначается людям с острым ишемическим инсультом в течение 48 часов после начала инсульта. Существуют доказательства среднего (умеренного) качества, которые вызывают обеспокоенность по поводу увеличения числа серьёзных неблагоприятных событий при использовании церебролизина у людей с острым ишемическим инсультом. Дальнейшие исследования, вероятно, окажут существенное влияние на нашу уверенность в оценке рисков серьёзных неблагоприятных событий, связанных с применением церебролизина у людей с острым инсультом.

Kazan medical journal. 2018;99(1):174
Beta-blockers for hypertension

Какова цель этого обзора? Целью этого Кокрейновского обзора было оценить, уменьшают ли бета-блокаторы число смертей, инсультов и сердечных приступов, связанных с высоким артериальным давлением у взрослых. Мы собрали и проанализировали все соответствующие исследования, чтобы ответить на этот вопрос, и нашли 13 подходящих исследований.

Являются ли бета-блокаторы такими же эффективными, как и другие лекарства, при их использовании для лечения взрослых с высоким артериальным давлением? Бета-блокаторы не были такими же эффективными, как другие классы лекарств, например диуретики, блокаторы кальциевых каналов и ингибиторы ренин-ангиотензиновой системы, в предотвращении числа смертей, инсультов и сердечных приступов. Большинство из этих результатов получены по одному бета-блокатору под названием атенолол. Однако бета-блокаторы представляют собой разнородную группу лекарств с различными свойствами, и нам необходимо больше качественно проведённых исследований в этой области.

Что было изучено в этом обзоре? Миллионы людей с повышенным артериальным давлением страдают от инсультов, сердечных приступов и других заболеваний, и многие из них умирают. Эта ситуация может быть предотвращена при соответствующем лечении. Исследователи изучили различные лекарства для лечения высокого артериального давления. Каковы главные результаты этого обзора? Мы нашли 13 исследований, проведённых в странах с высоким уровнем дохода, в основном в Западной Европе и Северной Америке. В этих исследованиях было проведено сравнение между людьми, которые принимали бета-блокаторы и которые принимали другие лекарства или не получали никакого лечения.

Исследования показали следующее. Бета-блокаторы, возможно, оказывают незначительное влияние или вообще не влияют на число смертей среди людей, получающих лечение в отношении высокого артериального давления. Этот эффект, как представляется, аналогичен эффекту диуретиков и ингибиторов ренин-ангиотензиновой системы, но бета-блокаторы, вероятно, не так же эффективны в профилактике смерти от высокого артериального давления, как блокаторы кальциевых каналов. Бета-блокаторы могут сократить число инсультов, эффект, как представляется, аналогичен эффекту диуретиков. Однако бета-блокаторы могут быть не столь хороши в профилактике инсультов, как ингибиторы ренин-ангиотензиновой системы или блокаторы кальциевых каналов. Бета-блокаторы могут оказывать незначительное влияние или вообще не влияют на число сердечных приступов у людей с высоким артериальным давлением. Доказательства позволяют предположить, что этот эффект может не отличаться от эффектов диуретиков, ингибиторов ренин-ангиотензиновой системы и блокаторов кальциевых каналов. Однако в отношении людей в возрасте 65 лет и старше доказательства позволяют предположить, что бета-блокаторы, возможно, не такие же эффективные, как диуретики, в сокращении частоты сердечных приступов. Люди, принимающие бета-блокаторы, более вероятно будут иметь побочные эффекты и прекратят лечение, по сравнению с людьми, принимающими ингибиторы ренин-ангиотензиновой системы, но, возможно, различия в побочных эффектах между бета-блокаторами, диуретиками и блокаторами кальциевых каналов незначительны или отсутствуют.

Насколько этот обзор актуален? Авторы обзора провели поиск исследований, опубликованных по июнь 2016 г.

Kazan medical journal. 2018;99(1):174-175
Pentasaccharides for the prevention of venous thromboembolism

Актуальность. Венозная тромбоэмболия (ВТЭ) - состояние, при котором в венах образуются сгустки крови (тромбы). Оно включает два состояния: тромбоз глубоких вен (ТГВ) и тромбоэмболию лёгочной артерии (ТЭЛА). ВТЭ встречается более чем у 10% пациентов в больницах и является третьей наиболее распространённой причиной смерти среди них. Таким образом, людям, которые подвержены высокому риску ВТЭ, необходима эффективная профилактика. Стандартный метод профилактики - применение антикоагулянта, например низкомолекулярного гепарина (НМГ) или варфарина у ортопедических пациентов. В последние годы другой тип антикоагулянта, пентасахарид, показал в клинических испытаниях хороший антикоагулянтный эффект. В настоящее время доступны три типа пентасахаридов, а именно: короткого действия - фондапаринукс, длительного - идрапаринукс и идрабиотапаринукс.

Основные результаты. В наш систематический обзор были включены 25 исследований с 21 004 участниками (актуально на март 2016 г.). Мы не нашли исследований, посвящённых профилактике ВТЭ препаратами длительного действия - идрапаринуксом и идрабиотапаринуксом. В связи с этим мы включили лишь исследования, посвящённые препарату короткого действия фондапаринуксу в профилактике ВТЭ. Доказательства умеренного и высокого качества свидетельствуют о том, что фондапаринукс эффективен в краткосрочной профилактике ВТЭ в сравнении с плацебо. Он может снижать общую частоту ВТЭ, ТГВ, ТЭЛА и выраженность симптомов ВТЭ, но не показывает никаких различий в числе смертей в сравнении с плацебо. Доказательства низкого и умеренного качества свидетельствуют о том, что фондапаринукс эффективен в краткосрочной профилактике ВТЭ в сравнении с НМГ. Он может снижать общую частоту ВТЭ и ТГВ, но не показывает никаких различий в числе смертей в сравнении с НМГ. Однако в то же время фондапаринукс повышает частоту серьёзных кровотечений в сравнении с плацебо и НМГ. Таким образом, при выборе фондапаринукса для профилактики ВТЭ следует обратить внимание на риск кровотечения у пациента. Большая часть данных была получена из исследований среди пациентов, перенёсших ортопедические операции. Таким образом, выводы преимущественно касаются этих пациентов. Сведения о применении фондапаринукса при других состояниях, таких как внутренние болезни и абдоминальные операции, ограничены.

Качество доказательств. Мы снизили оценку качества доказательств в связи с небольшим числом событий, приводящим к неточности, а также различиями и несогласованностью исследований. Нам необходимы дополнительные высококачественные клинические испытания, чтобы подтвердить эффективность и безопасность фондапаринукса.

Kazan medical journal. 2018;99(1):175-176
Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease

В чём суть проблемы? У пациентов с хронической болезнью почек (ХБП) повышен риск развития фибрилляции предсердий (ФП), которая часто может приводить к инсульту или системной эмболии. Стандартной терапией для предупреждения ФП является подобранный по дозе варфарин, но он может увеличить риск возникновения кровотечений, поэтому требуется постоянный терапевтический мониторинг. Недавно были разработаны новые пероральные антикоагулянты [прямые пероральные антикоагулянты (ПОАК)] в качестве альтернативы варфарину. Мы проанализировали доказательства эффектов ПОАК по сравнению с варфарином для профилактики инсульта и системной эмболии у пациентов с ФП и ХБП.

Что мы сделали? Мы обнаружили пять исследований, в которых эффекты ПОАК (апиксабан, дабигатран, эдоксабан и ривароксабан) сравнивали с таковыми варфарина в подобранной дозе. 12 545 участников этих пяти исследований имели неклапанную ФП и умеренное нарушение функции почек. В этих исследованиях представлены данные обо всех комбинированных исходах инсульта и системной эмболии в качестве основной конечной точки эффективности и тяжёлых кровотечений в качестве основной конечной точки безопасности. Средний период наблюдений колебался от 1,8 до 2,8 года. Доказательства актуальны на август 2017 г.

Что мы нашли? ПОАК, вероятно, уменьшали частоту возникновения инсультов и системной эмболии в качестве основной конечной точки эффективности по сравнению с варфарином. Кроме того, ПОАК могут несколько снизить частоту возникновения тяжёлых кровотечений в качестве основной конечной точки безопасности по сравнению с варфарином.

Выводы. Этот обзор продемонстрировал, что ПОАК, так же как и варфарин, предотвращают инсульт и системную эмболию без увеличения случаев тяжёлых кровотечений у пациентов с ФП и ХБП. Согласно GRADE, качество доказательств было средним для первичной конечной точки эффективности из-за неточностей и низким для первичной конечной точки безопасности из-за несоответствия результатов исследований и неточностей. Результаты этого исследования в основном относятся к пациентам с ХБП 3-й стадии, поскольку мы не смогли оценить пациентов с 4-й и 5-й стадией ХБП.

Kazan medical journal. 2018;99(1):176

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