Том 31, № 4 (2024)

Most studies examining the safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation have focused on major, life-threatening bleeding events. However, clinically relevant non-major bleeding (CRNMB) may lead to unnecessary prolonged withdrawal of DOACs, both by the patient and the physician, and, as a result, increase the risk of death and/or systemic thromboembolic complications. The article presents several classifications of types of bleeding: BARC, GARFIELD-AF, ISTH. An analysis of modern literature was carried out, as a result of which it was revealed that the incidence of CRNMB is higher than major bleeding and varies from 6.69% to 17.4%, the density of events for CRNMB was maximum 22.7 cases (95% confidence interval [16.3–30.8] per 100 patient-years) and the frequency of such bleeding had a direct relationship with the age of the patients studied: the older the population, the more frequent episodes of CRNMB occurred. The most common localization of CRNMB was in the gastrointestinal tract – up to 47%, genitourinary tract – up to 32.6% and skin – up to 17.6%. Based on the recommendations of leading cardiological societies to prevent bleeding, in addition to the HAS-BLED scale, additional prevention methods are presented, taking into account the age characteristics of the patient. As a current approach in the treatment of bleeding, it is recommended to determine the severity, identify and eliminate the source of bleeding. Discontinuation of DOACs during bleeding requires a personalized approach and, most importantly, prompt resumption of DOACs. At the same time, CRNMBoften require discontinuation of only one dose of the drug. Given that studies rarely present data on the incidence and pattern of CRNMB or data are presented in conjunction with other types of bleeding, it would be advisable that future studies regarding the safety of DOACs include more detailed information on the incidence of CRNMB, risk factors for its development, especially in geriatric patient populations.

Background. In modern conditions of combating cardiovascular mortality, there are problems of patient’s weak motivation and low involvement in cardiac rehabilitation (CR) programs.

Objective. Determination of the relationship between the psychological status of patients who underwent myocardial revascularization and exercise tolerance at the outpatient stage of rehabilitation.

Methods. The open clinical trial included 85 patients (66 men and 19 women) 1 month after coronary revascularization, who had previously completed the first and/or second stages of CR and were referred to the outpatient stage. The age of the patients ranged from 42 to 79 years, mean age 60.8±7.23 years. Two groups were identified: 1st – 35 (41.18%) patients who underwent percutaneous transluminal coronary angioplasty (PTCA); 2nd – 50 (58.82%) patients after coronary artery bypass grafting (CABG). Under standard conditions, a face-to-face survey using “Hospital Anxiety and Depression Scale” (HADS, anxiety subscale HADS-A, depression subscale HADS-D), short form of quality of life assessment “SF-36” was conducted. In order to determine exercise tolerance, a six-minute walk test (SMWT) was performed.

Results. When studying correlation relationships, an inverse relationship was revealed between SMWT distance and age (r=-0.407; p=0.001), HADS-A (r=-0.443; p=0.000), HADS-D (r=-0.356, p=0.003), direct relationship with the Mental Health indicator (r=0.269; p=0.027), integral indicators of the “physical component of health” (r=0.266; p=0.029) and the “mental component of health” (r=0.327; p=0.007).

Conclusion. The psychological status of the patient can influence the SMWT distance, which plays an important role in the development of individual CR programs after coronary revascularization at the outpatient stage. This fact leads to defects in the selection of optimal physical activity when drawing up a physical training protocol. The combined use of two scales (HADS and SF36) contributes to a deeper assessment of the patient’s initial psychological status, which makes it possible to recommend early inclusion of a psychologist or psychotherapist in a multidisciplinary team to correct disorders.

Background. Prevention of cardiovascular diseases requires early identification of people at high risk so that effective dietary, lifestyle, or drug interventions can be implemented.

Objective. Evaluation of the clinical, instrumental and laboratory parameters as markers of the development and progression of cardiovascular diseases (CVDs).

Methods. Assessment of actual nutrition and physical activity at home, anthropometric studies, assessment of body composition, study of energy metabolism with determination of daily nitrogen excretion, study of indicators of resting metabolism and macronutrient metabolism. Laboratory studies included the general blood test, clinical urinalysis, analysis of biochemical markers of lipid, protein and carbohydrate metabolism, parameters of the functional activity of the hepatobiliary system, blood coagulation system, hormonal profile indicators, electrolyte metabolism, vitamin status, lipid peroxidation products and enzymes of the antioxidant protection system.

Results. In 956 patients with cardiovascular diseases, specific factors predicting the development of coronary artery disease (CAD) were identified: silent myocardial ischemia, post-infarction cardiosclerosis, condition after surgical treatment, angina pectoris 1 functional class. Prediction of the risk of developing a particular clinical event from specific quantitative or binary indicators of the metabolic status of patients was carried out using the Pearson Chi-square test.

Conclusion. In one clinical case of CAD, biomarkers of metabolic status were identified as key, in another case – parameters of the clinical course of atherosclerotic disease, in the third and fourth – their combination. Taking into account the presence of these factors, it is possible to carry out measures for their adequate and timely correction, thereby preventing the development and progression of these nosological forms.

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease that not only affects the liver with the development of complications up to cirrhosis, but also associated by an increased risk of developing such diseases/conditions such as diabetes mellitus, cardiovascular pathology, metabolic syndrome, as well as oncological diseases. In this regard, NAFLD represents a medical and social burden associated with high mortality and a decrease in the quality of life of patients. To increase the awareness of physician about this pathology and a systematic approach to pharmacotherapy, in 2022 For the first time in Russia, a National Consensus on the management of adult patients with NAFLD has been released. According to the consensus, the criteria for rational drug therapy are not only the effect on slowing the progression of liver damage up to the regression of steatosis, steatohepatitis and fibrosis, but also a decrease in cardiometabolic risk factors. Currently, only ursodeoxycholic acid (UDCA) meets these requirements. In addition, this drug has a synergistic lipid-lowering effect when combined with statins, which makes it the drug of choice for the treatment of NAFLD at any stage. Considering the high efficiency and large evidence base, UDCA is included in the recommendations on NAFLD and combined pathology by various medical associations: gastroenterological, cardiological, therapeutic.

The history of the discovery and use of probiotic strains in clinical medicine goes back more than a hundred years. Numerous studies in recent years have convincingly demonstrated that modulation of the intestinal microbiota (IM) is one of the key pathogenetic links in the formation and persistence of symptoms of irritable bowel syndrome (IBS), which makes the strategy of prescribing probiotics pathogenetically justified both for the improving the relief of symptoms and for the maintaining long-term remission of the disease. Targeted action and prolongation of the course of therapy to 8–12 weeks are considered as the main principles for prescribing probiotics for IBS, which allows increasing the effectiveness of therapy for patients. From this standpoint, the probiotic strain Bifidobacterium longum 35624^® (Symbiosis Alflorex) with high proven efficacy and safety in the treatment of patients with IBS is of particular interest.

Nowadays, there is a rapid increase in the number of elderly patients, requiring a significant expansion of our understanding of the basics of the “biology of aging,” or senescence. The pulmonary system consists of a unique set of cells of various types, which are subject to constant chemical, mechanical, biological, immunological, and xenobiotic stress throughout human life. To date, the mechanisms of lung senescence and the reasons for the increased risk of parenchymal pulmonary diseases, fatal respiratory infections, and primary lung cancer among patients in the older age group remain poorly understood. In this review, we tried to present the molecular and cellular mechanisms of lung aging, especially those predisposing to the development of pulmonary diseases, in the form of a scientific review with discussion.

Background. COVID-19 has had a huge impact on the health and economy of the world. While most people with COVID-19 illness recover fully, others continue to experience chronic symptoms, including autonomic manifestations. Meeting the needs of Long-COVID patients requires a significant investment of resources and funding for both clinical care and research. It is imperative to act during this window of opportunity in hopes of reducing or decreasing the symptom burden for these patients.

Objective. Evaluation of the prevailing symptoms and their dynamics in patients with a new coronavirus infection in the acute and subacute periods of the disease.

Methods. The study analyzed the questionnaires of 113 patients followed-up on an outpatient basis in several clinics in Belgorod. The authors] questionnaire was a survey in which, on a 10-point scale, the patient had to indicate the intensity of the sign (symptom, symptom complex) in the acute stage (the first 4 weeks of the disease) and the degree of intensity of symptoms more than 3 weeks after the initial visit (subacute period of the disease, or the beginning of “post-Covid syndrome”).

Results. The results of our survey showed that in the acute phase of COVID-19, asthenovegetative syndrome, manifested by weakness and fatigue (96%); thermoregulation disorders (95%); impaired perception of taste and smell (72%) were most often observed. At the same time, in the “subacute” phase (the beginning of the “post-COVID syndrome”), in addition to asthenovegetative syndrome (82%), tachycardia (67%) and emotional and mental disorders, asthenia (63%) came to the fore.

Conclusion. The study, conducted at the height of the pandemic, allowed the authors to identify the leading symptoms of the acute and subacute (early post-Covid) phases of the new coronavirus infection. Trends in the dynamics of symptoms have been identified, which makes it possible to more accurately select approaches to the treatment of such patients at different periods of the disease.

The review presents differential diagnosis and pathogenetic therapy for back pain (BP). In the treatment of BP associated with spondylosis and spondyloarthrosis, slow-acting symptom-modifying drugs SYSADOA containing chondroitin sulfate remain promising. Extensive experience has been accumulated in the successful use of a biological drug for parenteral administration, Alflutop, for BP. The presented results of observational and placebo-controlled studies give reason to believe that the analgesic and anti-inflammatory effects of Alflutop, applied paravertebrally and/or intramuscularly at a dose of 2.0 ml every other day No. 10 for vertebrogenic lumboischialgia of chronic course, appear already in the 2nd week and increase during 3 months. Alflutop’s early analgesic effect distinguishes it from almost all injectable drugs belonging to the SYSADOA class known in the Russian Federation. During therapy with Alflutop, the need for nonsteroidal anti-inflammatory drugs (NSAIDs) is significantly reduced, and, consequently, the risk of developing threatening gastrointestinal, cardiovascular and renal side effects is decreased. In order to prevent exacerbations, it is advisable to carry out repeated courses of treatment 2–3 times a year.

Bettolepsy is an episode of loss of consciousness during a coughing attack. Bettolepsy is a rare syndrome. Among patients with pulmonary diseases, the prevalence is about 18%, in the general population - about 0.6%. The following options are being considered: loss of consciousness without convulsions, loss of consciousness with convulsions and occasionally pelvic disorders; fainting followed by confusion; seizures followed by “non-coughing” epileptic seizures; seizures in people who previously suffered from epilepsy; coughing syncope in people with organic brain lesions, venous encephalopathy. As a result of a sharp increase in intrathoracic and intra-abdominal pressure, the nucleus of the vagus nerve in the medulla oblongata is stimulated, blood flow to the left ventricle of the heart decreases, cardiac output falls, blood pressure decreases, sharp bradycardia and transient ischemia of the reticular formation of the brain stem occur, which leads to fainting. Most often, cough fainting occurs in men 35–40 years old, smokers and overweight. The frequency of attacks ranges from 2–3 attacks over 5–10 years to 10–12 attacks per day. Differential diagnosis should be carried out with epilepsy using electroencephalography. Treatment of bettolepsy includes therapy for the underlying disease – antibacterial, hormonal therapy, bronchodilators, antitussive drugs; due to positive effect of gabapentin, opinion about the neuropathic nature of the disease has been suggested. This literature review discusses the physiology of cough, etiology, pathogenesis, clinical picture, diagnosis and treatment options for cough syncope, clinical cases, and provides data from articles by Russian-speaking and foreign authors.

Background. The high incidence of osteopenia and osteoporosis in patients with chronic obstructive pulmonary disease (COPD) remains underestimated due to its asymptomatic course. According to the literature, impaired bone mineral density (BMD) in patients with COPD who have risk factors is of great interest for practical medicine and is widely studied. Taking into account the residence of the population of Kyrgyzstan at different geographical altitudes and the lack of data on the prevalence of osteopenia and osteoporosis, the study of their incidence in patients with COPD determines the relevance and objective of this study.

Objective. Evaluation of the incidence of osteopenia and osteoporosis in patients with COPD among residents of Kyrgyzstan living at different geographical altitudes.

Methods. 358 residents of Kyrgyzstan were examined. The patients were divided into 2 groups. The group 1 consisted of 158 permanent residents of the highlands (Naryn region, 1500–2500 m above sea level), mean age – 55.9±2.8 years; group 2 included 200 residents of low mountains (Bishkek, Chui Valley, 760 m above sea level), mean age – 56.0±2.8 years. Patients of groups 1 and 2 were divided into two subgroups (A and B): A – with COPD stages I–III according to GOLD, B – without respiratory pathology. BMD using T-score was determined according to the dual-energy X-ray absorptiometry data. The results were analyzed using the Statistica for Windows Version 10.0 program (Statsoft, Inc, USA). Quantitative data are presented as the mean value and its standard deviation M in the case of a normal distribution of the characteristic. Statistical significance of differences was determined at p≤0.05.

Results. In highland residents, the mean T-score was -1.9±0.1 SD, which corresponded to “osteopenia.” In residents of low mountains, the discussed indicator averaged 0.9±0.01 SD, which corresponded to the lower limit of the norm. In most cases, normal BMD values were recorded in residents of Bishkek who did not suffer from COPD. The largest number of study subjects with osteoporosis was identified among COPD patients of the first subgroups of the two groups (41.9% among residents of the Naryn region and 32.0% among residents of Bishkek, respectively). The COPD stage influenced the incidence of osteopenia. Thus, in high-altitude conditions, the largest number of patients with osteopenia (48.1%) had stage 1 COPD, in low-altitude conditions – 43.2%.

Conclusion. For residents of the highlands of Kyrgyzstan, the mean T-criterion value was -1.9±0.1 SD (“osteopenia”), for residents of the lowlands of Kyrgyzstan – 0.9±0.01 SD (lower limit of normal). In most cases, normal BMD values were recorded in residents of Bishkek who did not suffer from COPD. Among residents of the Naryn region, the largest number of patients with osteopenia had stage 1 COPD, and among residents of Bishkek – stage 2 COPD (43.2%).

Background. The prevalence of degenerative-dystrophic spine pathology, resistance to available methods of conservative and surgical treatment, and tendency to relapse prove the prospects of searching and implementing differentiated programs for medical rehabilitation of patients with this disease.

Objective. Improvement and increase the effectiveness of rehabilitation of patients with DDSD.

Methods. Various types of treatment for 33 patients with dorsopathy, advanced osteochondrosis, complicated by scoliotic deformity and instability of the spinal motion segment SMS), manifested by pain, poor posture, muscle-tonic syndrome, limitation of movements in the limbs or parts of the spine and carpal tunnel syndrome in the period 2016–2000.

Results. When analyzing the dynamics of the summary assessment of the condition of patients in the group without treatment, there was no dynamics of the condition; with the use of drug therapy, the dynamics of the summary assessment of the condition significantly improved; with the use of manual therapy and acupuncture, the dynamics of the summary assessment of the patients’ condition significantly improved.

Conclusion. The most effective type of treatment is considered to be courses of manual therapy and acupuncture, which make it possible to relieve not only pain and muscle-tonic syndrome, but also tunnel syndrome, as well as reliably level out postural disorders, limitation of movements in the limbs or parts of the spine.

Background. Creutzfeldt-Jakob disease (CJD) is a difficult to diagnose prion disease, characterized by the development of rapidly progressive dementia and a long incubation period, which leads to death within the first year in 90% of cases. Despite the existence of criteria for intravital diagnosis and modern technologies, histotyping of the material still remains the gold standard for making a final diagnosis. The sporadic form remains the most common among all types of CJD.

Objective. Analysis of current data on CJA, systematization of the information obtained to facilitate the differential diagnosis of CJD types.

Methods. Data from 11 studies with a total of 817 confirmed cases of CJD were used for this work. The phenotypic features for each known type and subtype were analyzed, and the systematic sequence of distribution of the PrPsc prion protein for the two most common types of CJD was also indicated.

Results. Due to the studies reviewed, we are convinced that the true diversity of CJD histotypes is much wider than previously thought. Along with typical M1, M2C, M2T, VV1, and VV2 CJD forms, researchers distinguish transitional forms – VV1–VV2, and subtypes with specific morphological features – MV 1C–2PL.

Conclusion. The obtained data can be applied in practice if it is necessary to differentiate the types of CJD

Objective. Evaluation of the effect of photodynamic therapy (PDT) with Chlorin E6-based photosensitizer (PS) used for the correction of involutional skin changes, on anxiety in a group of patients with a history of basal cell carcinoma (BCC) or actinic keratosis (AK).

Methods. 90 patients with a history of skin tumors were followed-up. Patients were stratified into two groups, the first included women aged 50–60 years, the second – women over 61 years of age. The PS «Khloderm» was used in this work. The patients’ anxiety scores were assessed using Spielberger-Khanin questionnaires. Additionally, questions about personal fear about cancer, fear of loss of external attractiveness were introduced.

Results. In the group of patients over 60 years of age with a history of of non-melanocytic neoplasms, PDT statistically significantly reduced the proportion of high anxiety levels. The levels of situational anxiety after a course of PDT changed, showing a statistically significant increase in the proportion of patients with a low anxiety level – from 42.2 to 66.7. An analysis of the patients’ personal fears after correction using PDT showed that the proportion of women who indicated a fear of loss of external attractiveness significantly decreased from the initial values in the group of patients under 60 years of age. After 1 year after PDT, the proportion of patients who experienced fear of loss of external attractiveness significantly decreased from the baseline, not only in the subgroup under 60 years of age, but also over 60 years of age, which may reflect the accumulated effect of PDT.

Conclusion. Against the background of PDT using LED lamps for the correction of involutional changes, there was a decrease in the indicators of personal fears of patients in terms of both loss of external attractiveness with age and fears associated with the underlying disease, which can be regarded as a normalization of the psychological aspect of quality of life in the presence of a burdened history of cancer.

The article presents a literature review with detailed discussion of the epidemiology, etiology and pathogenesis of the accessory spleen; its most common locations are presented, which is supported by computed tomography and magnetic resonance imaging data from a personal archive; possible clinical manifestations of the accessory spleen are analyzed, its histological structure is examined in detail. Modern approaches to the diagnosis and treatment of this pathology, as well as issues of differential diagnosis, are discussed.

Background. Breast cancer maintains a leading position in the structure of morbidity and mortality from malignant neoplasms in women around the world. The heterogeneity of the course of this disease and the inevitable formation of resistance to antitumor drug therapy in its common forms remain key problems in clinical oncology. The discovery of mutations in the PIK3CA gene, encoding the catalytic subunit p110-α of phosphatidylinositol 3-kinase (PI3K), identified a target for therapeutic intervention and the creation of an effective drug alpelisib.

Objective. Analysis of the frequency and spectrum of PIK3CA mutations in Russian patients with EC+/HER2-breast cancer within one center.

Methods. The study included 42 patients with ER+/HER2- breast cancer. The study was carried out on a closed COBAS amplifier. After microdissection of the material, deparaffinization and DNA extraction, DNA concentration was analyzed using a Qubit fluorimeter, followed by COBAS sets of 1, 4, 7, 9 and 20 exons using a closed-type amplifier. The validity of all statements and samples was determined by the COBAS 4800 program. Information on the clinical and morphological characteristics of the tumor was extracted from the regional information system. Statistical analysis was performed using StatTech 4.1.1 software.

Results. Samples from 42 patients were tested. The average age of the patients at the time of diagnosis was 59.8 years. There was a predominance of patients with the luminal B HER2-negative subtype. Mutations in the PIK3CA gene were detected in 17 samples out of 42, which amounted to 40.5%. The 3 most common mutations accounted for 82% of cases: p.H1047X (6/17, 35%), pE542K (4/17, 23.5%) and p. E545X (4/17, 23.5%). A total of 6 mutations were detected in exon 20, 8 mutations in exon 9, and 3 mutations in exon 4 of the PIK3CA gene. In addition, 1 case of double mutation N345K-H1047R was identified. The mean age at diagnosis was 63.4 years in the group with a mutation in the PIK3CA gene and 57.4 years in the group without a mutation in the PIK3CA gene (p=0.14). The results of the analysis of the relationship between clinicopathological characteristics (stage, molecular subtype of the tumor, the presence of visceral metastases, localization and number of affected areas) did not differ statistically and clinically significantly between the groups of patients with and without a mutation in the PIK3CA gene.

Conclusion. The obtained data on the spectrum of somatic PIK3CA aberrations can be used for planning treatment with PI3K inhibitors in our population, for organizing molecular genetic testing of breast cancer patients in a regional dispensary and outside the region. It is planned to continue this study and evaluation the association of the PIK3CA gene mutation with the clinical and morphological characteristics of breast cancer.

A review of the clinical pharmacology of a new class of oral hypoglycemic drugs, sodium-glucose cotransporter-2 inhibitors (SGLT-2 inhibitors, or gliflozins), is presented. The main mechanism of action of SGLT-2, as well as other metabolic, cardiovascular, and renal effects, which are classified as pleiotropic class effects, is described. Data on the pharmacodynamics and pharmacokinetics of drugs (dapagliflozin, cancgliflozin, empagliflozin, ertugliflozin, ipragliflozin, luseogliflozin, sotagliflozin), side effects and drug interactions are discussed. Data on the clinical pharmacology of the SGLT-2 class will contribute to a better understanding of the underlying mechanism of action and pleiotropic effects that provide cardioprotective and renoprotective effects.

The article provides a review of the literature on the topic of anti-doping education for medical students to counter the use of stimulants in sports. The pharmacological classification of central nervous system stimulants registered in the Russian Federation is considered in comparison with the RUSADA classification. The list of prohibited substances is analyzed on the basis of regulatory documentation, mechanisms of action and side effects of stimulants of different classes, and their effect on the athlete’s body. This article is aimed at raising awareness among medical students about the negative consequences of doping and violating anti-doping rules.