[The expert questions in practice of rheumatologist].

The rheumatic diseases are a source of serious medical, psychological, social problems both for individual and society. This pathology is characterized by: wide prevalence, often early onset, continuously progressive course. All this is resulted in at first regular episodes of temporary disability and later to disability. Even timely and adequate therapy provide no guarantee for absence of disease progression in all patients. The rheumatologist is to know both clinical guidelines and legislative acts regulating issues of determining disability. The characteristic of The medical social expertise and all processes related to referral of patient, examination, decision-making are characterized by strict compliance with legislative acts which detail all these steps are spelled out in detail. Actually, the legislation of the Russian Federation includes orders and resolutions by the Ministry of Health and the Ministry of Labor and Social Protection which are significant both for employees of bureau of medical social expertise and for physicians (including rheumatologists) of ambulatory polyclinic institutions and hospitals. The awareness about these laws is detailed in professional standards for various specialties.

[An assessment of cerebrolysin effect on BDNF level in patients with post stroke aphasia depending on carbohydrate metabolism disorders].

AIM: We carried out an open randomized controlled study to explore the changes in the rate of speech recovery and BDNF concentrations in patients with left-hemisphere stroke and carbohydrate metabolism disorders (diabetes mellitus type2 or prediabetes) who received cerebrolysin. MATERIAL AND METHODS: A study included 60 inpatients of the Center of Speech Pathology and Neurorehabilitation. Neuropsychological examination was performed at baseline and after the treatment was completed. We determined aphasia type and quantitatively assessed speech in scores which reflected the severity of speech impairment. BDNF serum concentrations were measured. RESULTS: Clinical efficacy of cerebrolysin (intravenously in dose 20 ml in 100 ml of physiological solution, 5 days a week, during 4 weeks) used in addition to standard neurorehabilitation measures in patients with post stroke aphasia of different severity was demonstrated. This treatment was most effective in patients with very marked and marked speech impairment that was confirmed by the maximal possible improvement of speech during the first course of neurorehabilitation measures, in particular in a subgroup of patients without carbohydrate metabolism disorders. A significant increase in BDNF concentrations was an additional evidence of this improvement. CONCLUSION: The use of cerebrolysin in the complex treatment of patients with post stroke aphasia of different severity improves the prognosis of their rehabilitation.

[Development of main disturbances of hemostasis in patients with obesity].

According to current views obesity especially with increased amount of visceral fat is characterized by prothrombogenic changes of hemostasis and fibrinolysis. This combined with insulin resistance, compensatory hyperinsulinemia, disturbances of carbohydrate metabolism, atherogenic dyslipidemia and hypertension substantially increases risk of origination and progression of cardiovascular diseases. Results of our study demonstrate high prevalence of various prothrombogenic abnormalities in coagulation and anticoagulation systems in patients with visceral obesity and metabolic syndrome (MS). Disturbances of hemostasis were detected by such screening methods as measurement of APTT, INR and concentration of fibrinogen in blood plasma. We received data on positive association of severity of some abnormalities of hemostasis with anthropometric and biochemical parameters of obesity and MS, parameters of lipid and carbohydrate metabolism. Revealed disturbances of hemostasis create prerequisites for development of thrombophilia and make additional contribution to increase of cardiovascular risk in this category of patients. This dictates necessity of more thorough and deepened examination of patients with visceral obesity and MS with the aim of detection and correction of pathological changes of lipid and carbohydrate metabolism, system of hemostasis and fibrinolysis at earliest stages.

[Selenium provision in heart failure of different aetiology].

Determination of selenium status of patients with chronic heart failure of various etiologies showed reduced provision of selenium compared with the control group. Statistically significant increased serum levels of selenium have occurred on average 35,9% after the correction. Intake of sea cabbage jam led to a significant increase in the level of selenium in serum only at patients with deficiency of this trace constituent.

[Ultrasonic tomography of neurogenic tumors of the orbit]. / Ul'trazvukovaia tomografiia neirogennykh opukholei orbity.

The results of a comprehensive ultrasonic examination of 12 patients with tumors of the eye orbit are described. A low echogenicity as well as heterogeneity of the echo-structure and of the contours' sharpness are the main sonographic features of the mentioned tumors. An examination of a vascularization degree in patients with gliomas of the optic nerve showed no blood circulation inside tumors; while a collateral blood circulation was detected in patients with meningiomas of the optic nerve. A compression of the ocular artery by the tumor and reduced hemodynamic indices were found to be typical. Finally, a triplex examination of the orbit makes it possible to diagnose tumors of the optic nerve.

[New drugs in the treatment of advanced colorectal cancer]. / Nye medikamenter i behandlingen av avansert kolorektalcancer.

BACKGROUND: Colorectal cancer is one of the leading cancers in industrialised countries in terms of incidence and mortality. Advanced colorectal cancer has traditionally been treated with 5-fluorouracil, alone or in combination with leucovorin. This treatment has shown response rates of 10-25%; however, little effect has been observed on survival. MATERIAL, METHODS AND RESULTS: In recent years, a number of new drugs for advanced colorectal cancer have been developed and tested. We have made a comprehensive survey of the literature and find that phase II and phase III clinical studies show improved response rates compared to the traditional use of 5-fluorouracil and leucovorin. Thymidylate-synthase inhibitors, oxaliplatine and topoisomerase inhibitors, used singly or in combination, improve response rates and show a significant effect on survival in patients with metastatic colorectal disease. INTERPRETATION: Several new drugs now available in hospital treatment of metastatic colorectal cancer show improved response and increased survival compared to traditional 5-fluorouracil regimens.

[Fluorinated pyrimidines in oral treatment of advanced colorectal cancer]. / Fluorinerte pyrimidiner i peroral behandling av avansert kolorektalcancer.

BACKGROUND: For several years, fluorinated pyrimidines have been used in the treatment of advanced colorectal cancer, mainly in the form of intravenous injections of 5-fluorouracil (5-FU), alone or in combination with leucovorin. Oral treatment with 5-FU has been difficult because of high toxicity and low bioavailability. MATERIAL, METHODS AND RESULTS: Increased knowledge of the metabolism of 5-FU, reviewed in this article, has led to the development of a number of new oral drugs for the treatment of advanced colorectal cancer. Administration of prodrugs and inhibitors of 5-FU-catabolic enzymes has led to stable and high levels of active drug. Several drugs have shown promising results in new clinical trials. INTERPRETATION: New 5-FU related drugs for oral administration show results comparable to those of the cytotoxic drugs that have been administered in hospital. In the future, general practitioners could possibly treat and follow up a larger proportion of these patients.

Comparative assessment of Fontan operation in modifications of atriopulmonary and total cavopulmonary anastomoses.

OBJECTIVES: The optimal technique of the Fontan operation remains disputable. This investigation was aimed at the comparison of atriopulmonary and total cavopulmonary anastomoses. METHODS: The results of 81 operations of total cavopulmonary and 69 operations of atriopulmonary anastomosis, performed from 1983 to 1995 were analysed. A control study was carried out 1-10 (3.7 + 0.2) years after the operation in 80 patients (36 after total cavopulmonary and 44 after atriopulmonary anastomoses). 70 patients were studied several times. Cardiac catheterization was done in 70 patients. In 78 patients central hemodynamical indices were studied during exercise. RESULTS: Preoperative hemodynamical indices were not reliably different in the two groups. Early mortality after total cavopulmonary anastomosis was 15%, after atriopulmonary anastomosis 23%. The highest mortality was seen when the criteria of Choussat et al. (Choussat et al. Pediatric Cardiology. Edinburgh: 1977:559-566) were surpassed. In the early postoperative period after total cavopulmonary anastomosis circulatory insufficiency was less marked, transsudation from pleural cavities was reliably lower (15.3 + 1.2 versus 25.5 + 1.8 ml/kg/day, P < 0.01). Arrhythmias were more common after total cavopulmonary anastomosis (18.5 versus 12%). Late mortality after total cavopulmonary anastomosis was 6%, after atriopulmonary anastomosis 12%. 82% of patients after atriopulmonary anastomosis and 81% after total cavopulmonary anastomosis were in NYHA classes 1 and 2.7% of patients after total cavopulmonary anastomosis and 11% after atriopulmonary anastomosis were reoperated. Physical tolerance rose stepwise in both groups and by the third post-operative year reached 75% of normal level. At this time we saw the most optimal hemodynamical indices during exercise. However, the best hemodynamics during exercise were seen after atriopulmonary anastomosis. CONCLUSIONS: Total cavopulmonary anastomosis is accompanied by lower mortality rate and a more favourable course of early postoperative period. However, the best long-term functional results are obtained after atriopulmonary anastomosis.

[Changes in the functional state of patients after radical correction of tetralogy of Fallot]. / Dinamika funktsional'nogo sostoianiia bol'nykh posle radikal'noi korrektsii tetrady Fallo.

The authors studied the changes in the functional condition of patients in the immediate and long-term periods after radical correction of Fallot's tetralogy. The values of the heart pumping and contractile functions at rest and during bicycle ergometer exercise were studied by tetrapolar chest rheography; oxygen consumption was studied by spirometry. Thirty patients were examined in the early postoperative period and then 6 and 12 months after the operation. The values were compared with those in healthy children. It is shown that 12 months after the operation the clinical condition improves, the physical capacity for work increases, and the exercise response is more adequate. Adequacy of the correction of the anomaly is the main determinant of the patients' functional condition by this time.

[The role of associative opportunistic flora in the development of odontogenic inflammatory diseases of the maxillofacial area]. / Rol' assotsiativnoi uslovno-patogennoi flory v razvitii odontogennykh vospalitel'nykh zabolevanii cheliustno-litsevoi oblasti.

Morphologic and microbiologic study of the operation and biopsy specimens, obtained from 73 patients with odontogenic inflammatory processes has shown that in 38% of cases the inflammation was induced by mixed fungal and bacterial flora. Associations of staphylococci or streptococci with actinomyces, Candida, Penicillium, Rhodotorula were most frequently isolated. As a rule, weak patients developed odontogenic inflammatory processes with mycotic involvement, these processes often taking a chronic course. Qualitative composition of the fungal-and-bacterial associations should be borne in mind when planning therapeutic measures for such patients.

[Functional assessment of the state of patients after Fontan's operation]. / Funktsional'naia otsenka sostoianiia bol'nykh posle operatsii Fontena.

A bicycle ergometric test was performed in 27 patients 2.5 months to 5 years after Fontana's operation in order to study their physical working capacity and major parameters for cardiac pump and contractile functions by tetrapolar chest rheography and those for external respiration. In the early periods following the surgery, the patients showed a low physical working capacity with a respective reduction in the pump and contractile functions of the heart. In the late periods, in addition to positive clinical dynamics, there was an improvement of functional parameters for the cardiorespiratory system. The status in the majority of patients was steady-state for more than 2 years after the surgery.

[Results of the use of a graft with a monocusp in radical correction of Fallot's tetrad]. / Rezul'taty primeneniia zaplaty s monostvorkoi pri radikal'noi korrektsii tetrady Fallo.

The article deals with the results of complex study of the effect of pulmonary insufficiency on intracardiac hemodynamics and function of the heart in the immediate and late-term periods after radical correction of Fallot's tetralogy. Answers are also given to questions concerning the expediency of the use and functional adequacy of a xeno-pericardial monocusp in the closure mechanism of the pulmonary artery valve. The study showed that massive pulmonary regurgitation has a negative effect on the functional condition of the right ventricle in late-term postoperative periods. Convincing data were obtained which allow a graft with a monocusp of a bull's pericardium to be recommended for further clinical use to prevent insufficiency of the pulmonary artery valve after radical correction of Fallot's tetralogy.

[Functional state of the cardiorespiratory system in healthy children at rest and during the bicycle ergometry test]. / Funktsiia kardiorespiratornoi sistemy u zdorovykh detei v pokoe i pri veloérgometricheskoi nagruzke.

Altogether 25 healthy untrained children aged 9 to 12 years were examined. There were 11 boys and 14 girls. The following parameters were measured at rest and during bicycle ergometry: the heart rate, oxygen consumption, pulmonary ventilation, metabolic units, the ratio of oxygen consumption increment, oxygen pulse, stroke and cardiac indices, index of the Q-Z interval and work fitness. The ECG was recorded as well. During exercise, adequate reaction of the cardiorespiratory system was characterized by linear growth of the heart rate, cardiac index and oxygen consumption together with a proportional shortening of the Q-Z interval. At all levels of exercise the girls manifested more pronounced chronotropic stimulation, leading to the attainment of the submaximal heart rate (1.5 Watt/kg). On chronotropic delay overtension of inotropic function was demonstrable in children exposed to high loads, which was accompanied by restriction of the cardiac index growth.

[Total cavo-pulmonary anastomosis in the surgery of complicated congenital heart defects]. / Polnyi kavopul'monal'nyi anastomoz v khirurgii slozhnykh vrozhdennykh porokov serdtsa.

The authors discuss experience in 8 operations for total cavo-pulmonary anastomoses in patients with various complicated congenital heart anomalies in which radical or anatomical correction could not be undertaken. The operation for total cavo-pulmonary anastomosis is an alternative of Fonten's method since many authors claim that the last-named has some shortcomings. Total cavo-pulmonary anastomosis was established in 4 stages under conditions of extracorporeal circulation. End to side cavo-pulmonary anastomosis was formed in the first stage; the proximal end of the divided superior vena cava was joined to the pulmonary artery in the second stage; the communication between the heart and pulmonary artery was closed in the third stage, and, finally, a tunnel was formed between the inferior and superior venae cavae by means of a xenopericardial flap in the fourth stage. Six patients tolerated the operation successfully. The immediate postoperative period was more favourable than after Fonten's operation. However, to come to a deeper general conclusion and compare the two methods clinical material must be accumulated and the long-term results of the operations studied.

[Experimental candidiasis of the mouth mucosa under conditions of the inhibition of leukopoiesis]. / Eksperimental'nyi kandidoz slizistoi polosti rta v usloviiakh podavleniia leikopoéza.

In the experiments on rats (25--experimental rats, 15--the control group) using histological and electron microscopic methods the authors studied the nature of inflammatory response in the mouth cavity mucosa. Inflammatory response had an acellular nature with the predominance of alternative processes.

[Mechanisms of adaptation of the cardiorespiratory system to physical loads in cardiosurgical patients]. / Mekhanizmy adaptatsii kardiorespiratornoi sistemy k fizicheskim nagruzkam u kardiokhirurgicheskikh bol'nykh.

Problems related to the assessment of systemic oxygen transport and central hemodynamic parameters at exercise tests after surgical correction of congenital and acquired heart diseases are discussed. Several types of adaptation to stress have been identified. Noninvasive direct measurement of cardiac output under stress is shown to be useful as cardiac output values may be different where oxygen consumption levels are similar. It is suggested that the results may be used for functional assessment of surgical outcomes and the choice of treatment and rehabilitation strategy.