[Drug therapy's new options in the treatment of the severe irritable bowel syndrome].

BACKGROUND: Stress, individual characteristics of each patient, visceral hypersensitivity and intestinal motility have the key importance in the pathogenesis of irritable bowel syndrome (IBS). In recent years, there has been growing interest in the use of selective serotonin and norepinephrine reuptake inhibitors (SNRIs) in the complex therapy of IBS patients with somatoform disorders. AIM: To examine the effectiveness of the SNRIs antidepressant therapy in the treatment of patients with IBS and diarrhea (IBS-D) with extraintestinal manifestations. MATERIALS AND METHODS: 42 patients with severe IBS and diarrhea (IBS-D) were examined, among them 22 female with a median age of 32 years old (22; 38), and 20 male with a median age of 31 years old (25; 35). Treatment with duloxetine 60 mg/day was prescribed. The effectiveness of the therapy was assessed after eight weeks. The IBS clinical symptoms dynamics were assessed by the intensity of pain syndrome and bloating, which were determined using Visual Analogue Pain Scale (VAS), stool frequency and shape based on the Bristol stool scale; Visceral sensitivity threshold was assessed according to the Balloon dilatation test. There was studied the effect of the duloxetine on the extraintestinal manifestations of IBS. The psycho-emotional state was assessed using the Beck scale of anxiety and depression and the Spielberger-Khanin scale by psychiatrist, neurologist-vegetol. RESULTS: All patients showed positive dynamics after eight weeks duloxetine treatment: the decrease of pain syndrome from 9 (9; 10) to 2 (2; 3) points, bloating from 8 (8; 9) points to 2,5 (1; 3) points according to VAS, and defecation frequency from 10 (9; 12) to 2 (1; 2) times a day; the change of stool consistency from 6th (6; 7) to 3rd (3; 4) type. The visceral sensitivity threshold increased: the time of appearance of the first urge to defecate increased from 56 (34; 74) ml to 95 (80; 98) ml. Significantly decreased extraintestinal manifestations of IBS. In reassessing each patient's individual characteristics there were the decrease of the depression level according to the Beck scale from 26 (23; 32) to 11.5 (10; 13) points and personal personal anxiety level according to the Spielberger-Khanin scale from 42.5 (35; 53) to 22 (20; 24) points, as well as the decrease of situational anxiety from 40 (37; 49) to 22 (21; 36) points. CONCLUSION: The severe course of IBS-D is mainly associated with the patients' individual characteristics and anxiety or anxiety-depressive syndromes. The positive impact of duloxetine therapy in severe IBS-D with extraintestinal manifestations is associated with the regulation of serotonergic and noradrenergic activity of the central.

[Visceral sensitivity in diagnostics and treatment of severe irritated bowel syndrome].

BACKGROUND: Irritable bowel syndrome (IBS) is a biopsychosocial model based on the malfunction of "brain-intestinal linking". AIM: To improve diagnostics of the severe IBS accompanied with somatoform disorders by using balloon dilatation test (BDT) and optimize the therapy by using antidepressants from the serotonin and noradrenaline reuptake inhibitor type. MATERIALS AND METHODS: 61 patients with severe IBS and diarrhea were examined, among them 29 female with a median age of 31 years old (24; 36), and 31 male with a median age of 31 (24; 36) years old. All patients were randomized into two groups, group 1 consisted of 30 patients (15 female, 15 male), group 2 consisted of 31 patients (15 female, 16 male). The symptoms of all patients were assessed using the Visual Analogue Pain Scale (VAS Pain), visceral sensitivity index (VIS) was assessed according to the J. Labus questionnaire (2007) and visceral sensitivity threshold was assessed according to the BDT, the psycho-emotional state was assessed using the Beck scale of anxiety and depression and the Spielberger-Khanin scale. Both group patients underwent a comparative effectiveness evaluation between the therapy based on the use of Trimebutine at a dose of 600 mg per day and the SNRI-Duloxetine therapy at a dose of 60 mg per day for 8 weeks. RESULTS: Patients from group with severe IBS and diarrhea who had undergone the antidepressant therapy showed the decrease of pain syndrome from 7 (5; 7) to 2.5 (2; 3) points according to VAS Pain; normalization of stool frequency from 7 (6; 9) to 2 (1; 2) times a day; normalization of stool consistency from 6 (6; 7) to 3 (3; 4) type; and decrease of VIS: first urge from 56 (34; 74) to 95 (80; 98) ml.; as well as the decrease of the depression level (Beck scale) from 26 (23; 32) to 11.5 (10; 13) points and anxiety according to Beck scale from 38 (31; 45) to 11 (10; 12), the decrease of personal anxiety level (Spielberger-Khanin scale) from 42.5 (35; 53) to 22 (20; 24) points, and the decrease of situational anxiety from 40 (37; 49) to 22 (21; 36) points. During the trimebutine therapy in group 1, the clinical symptoms of IBS have persisted. According to the BDT, the visceral sensitivity (HF) threshold remained at a low level. And the indicators of anxiety and depression remained at a high level according to the psychometric scales. CONCLUSION: The insufficient effect of the trimebutine therapy can be explained by the somatoform disorders persistence in patients from group 1. Meanwhile SNRI-duloxetine therapy in group 2 showed a clinical remission of IBS: such as a reliable relief from pain and diarrheal syndrome, as well as an increase in the HF threshold. Thus, Duloxetine is a promising treatment for severe IBS with somatoform disorders. BDT can be used as an objective criterion to diagnose and evaluate the effectiveness of therapy in patients with IBS.

[Motor activity in psychogenic arm palsy confirmed by polysomnography (clinical case)]. / Dvigatel'naia aktivnost' pri psikhogennom paraliche, zaregistrirovannaia pri polisomnografii (klinicheskii sluchai).

According to current criteria, the diagnosis of psychogenic motor defect is based on the tests which allow recording of movements in the pseudo-paralyzed extremity. Using polysomnography, electromyography and videomonitoring of motor activities during sleep, movements in the pseudo-paralyzed left arm were recorded in a patient with Munchhausen syndrome and psychogenic plegia in the left arm. A reduced motor activity in the left side of the body, in particular in the pseudo-paralyzed arm was observed as well. Possibilities of using movement monitoring during sleep for the diagnosis of psychogenic motor defect are discussed.

[Functional (psychogenic) vertigo]. / Funktsional'noe (psikhogennoe) golovokruzhenie.

Psychogenic (functional) vertigo is in second place by frequency after benign positional paroxysmal vertigo. It is often difficult to make the diagnosis, diagnostic program is expensive and traditional treatment often is not effective. This literature review covers current concepts on the terminology, clinical signs, pathogenesis and treatment approaches with regard to functional vertigo. Special attention is given to cerebral mechanisms of the pathogenesis including cognitive aspects.

[Functional disorders: pathogenesis and systematic of clinical presentation]. / Funktsional'nye rasstroistva: sistematika klinicheskikh proiavlenii i patogenez.

Functional disorders hold a prominent place in the clinical practice of physicians of different specialties. The difficulties in the diagnosis of functional disorders need expensive examinations, and standard treatment is, as a rule, is not effective. Currently, the pathogenesis of these disorders is considered in the frames of the biopsychosocial model. In this literature review, the authors present modern concepts of terminology, classification, main features and general trends of the course of functional disorders. Special attention is drawn to comorbidity, a role of psychogenic factors and cerebral mechanisms of the pathogenesis including cognitive aspects.

[Headaches of tension and psychogenic headaches: assessment of the treatment with venlafaxine].

The modern classifications of headaches include primary headaches, e.g., migraines and headaches of tension (HAT), and secondary psychogenic headaches of tension (PHT). Forty-one patients with chronic variants of HAT and PHT were studied. In the first step, 12 patients with HAT and 11 patients with PHT were compared by clinical and psychometric scores on the following scales (the VAS, the McGill Pain Questionnaire, the MMPI). In the second step, 11 patients with HAT and 7 with PHT were treated with venlafaxine XR (velaxin) in dose 75 mg/d during 2 months. It has been shown that PHT differs from HAT by pain intensity and relationship with functional-neurologic symptoms as well as by personality deviations measured with MMPI and correlations between the pain intensity and MMPI peaks. The 2 month treatment with velaxin has improved significantly the state of patients. The significant decrease of pain severity, amount of analgesics and pain-associated symptoms as well as the normalization of functions of antinociceptive systems (the increase in nociceptive flexor reflex threshold) were noted in both groups. It has been concluded that venlafaxine is an effective drug in the treatment of both HAT and PHT.

[Speech disorders in right-sided brain stroke].

The clinical picture revealed that right-sided brain stroke is often accompanied by some speech disturbances. The present paper aims at the analysis of literature devoted to speech disturbances in right-sided brain stroke. The paper addresses issues on lateralization of speech functions, in particular the role of the right hemisphere in speech activity and structure of speech pathology in right hemispheric foci are specified. Such clinical variants of speech disturbances as aphasia, disprosodia, dysartria, mutism and stammering are analyzed in depth. Types of speech disorders as well as possible mechanisms of their formation in dependence of the lesion localization on the brain axis (cortex, subcortical structures, stem, cerebellum) and size of brain lesion are reviewed.

[Familial transthyretin amyloidosis].

A case of familial transthyretin amyloidosis with TTR Cys 114 gene polymorphism is described (first in Russia and third in the world). The clinical picture of the proband was dominated by symptoms of autonomous polyneuropathy (orthostatic hypotension, erectile dysfunction, diarrhea, tachycardia, foot dyshydrosis) and of somatic nerve lesions (dumbness, impaired surface and deep sensitivity in the limbs). The patient presented with vitreous body opacity, disturbed eye movements, lateralized sensory symptoms, and difficulty of speech (baryphonia). Electromyographic quantitative autonomous testing and measurement of evoked sympathetic skin potentials confirmed affection of peripheral nerves. Heart ultrasound revealed restrictive amyloid cardiopathy. Histological analysis showed amyloid deposition in the intestines and sural nerve. The proband, his daughter, brother (monozygous twin), and brother's daughter had mutant TTR Cys 114 gene. The brother also had amyloid deposits in the absence of clinical signs of the disease. Analysis of familial medical history demonstrated autosomal dominant inheritance of this mutation in 4 generations. Its possible origin and clinical features of the disease are discussed.

[Quantitative indices of gait in patients with psychogenic and organic dysbasia].

The study aimed at comparison of quantitative indices of gait in patients with hysteria and organic dysbasia. Two groups of patients were studied - 28 patients with psychogenic dysbasia and 22 with organic gait disturbances (cerebellar ataxia in multiple sclerosis and post stroke hemiparesis). A control group included 10 healthy subjects. Space and temporal gait characteristics were investigated using an impregnation method (footprint), i.e. analysis of gait parameters by footprints. Step width (base) and length, step frequency and gait speed were assessed. All parameters were recorded both at normal speed and accelerated gait. At accelerated gait, changes of step base (SB) were in different directions: in patients with hysteria and controls SB decreased and in patients with organic dysbasia increased. SB index (ratio of SB at accelerated gait to that at normal speed) was <1 in 82% of patients with psychogenic dysbasia and 90% controls and >1 in 91% of patients with organic gait disturbances. Maximal differences were found between subgroups with psychogenic and organic ataxia and less marked differences - in paresis.

[Psycho-autonomic aspects in patients with gastroesophageal reflux disease, and functional esophageal disorders].

The subjects of the study were 79 patients (35 with functional esophageal disorders (FED), 24 with nonerosive reflux disease (NERD), and 20 with erosive reflux disease (ERD), who were selected on the basis of clinical complaints, 24-hour ph-study, and esophagogastroduodenoscopy. All the subjects were evaluated by means of clinical questionnaires and psychological tests: Beck depression test, Spielberg State-Trait Anxiety inventory (STAI), and Toronto alexithymia test (TAS). In FED and NERD patients vs. ERD patients the following abnormalities were observed more frequently: autonomic and functional somatic symptoms (apart from gastrointestinal tract (GIT) complaints) (p < 0.01), sleep disturbances (p < 0.01), fatigue (p < 0.01), eating behavior disorders (DEBQ) (p < 0.05), maternal overprotection in childhood (p < 0.05), psychophysioligical GIT reaction in childhood (p < 0.05), higher levels of state and trait anxiety (p < 0.05), and hypochondria (p < 0.05). The clinical symptom index (CSI) (the sum of stomach and bowel complaints to the sum of esophageal complaints ratio) was calculated. CSI in FED and NERD patients was 1.8, while CSI in ERD patients--0.1 (p < 0). Thus, compared to ERD patients, patients with FED and NERD were characterized by more pronounced emotional, motivational, and autonomic disorders. Besides, CSI demonstrated that the character of gastrointestinal dysfunction was more diffuse in NERD and FED and more local--in ERD patients.

[Psychophysiologic disorders in patients with functional disorders of upper sections of the gastrointestinal tract and with gastroesophageal reflux disease]. / Psikhovegetativnye narusheniia u bol'nykh s funktsional'nymi rasstroistvami verkhnikh otdelov zheludochno-kishechnogo trakta i gastroézofageal'noi refliuksnoi bolezn'iu.

The features of the psychovegetative status in patients with functional disorders of the esophagus and stomach (FD) and gastroesophageal reflux disease (GERD) are investigated. The methods included clinical, instrumental and psychometric examination. The patients of both groups had similar vegetative abnormalities and a tendency towards the growth of depression and anxiety parameters, did not differ in psychosocial factors, and had a wide range of psychovegetative abnormalities (PA). Lump in the throat, heartburn, epigastralgia (p < 0.01), depression, actual anxiety, alexitymia and vegetative disorders decreased in both groups (p < 0.05) after treatment with citalopram (20 mg per day) during 2 months. So PA are revealed in patients with FD and GERD, and citalopram reduces psychovegetative and GIT disorders.

[Psychogenic disorders of stance and gait as seen in videotaping]. / Psikhogennye narusheniia sotiania i khod'by po dannym videozapisi.

Psychogenic disorders of stance and gait were studied in 24 hysterical patients by video review analysis. In 30% of the cases, gait disorders were represented by pseudoataxia (gait with crossed legs or ataxia with sudden sidesteps); gait with dragging leg (sometimes with twisted foot and equino-varus posture); gait with flexed and/or buckling knees. Ancle and hip excess mobility, or hypermobility, proved to be rather typical, as well. The disorder types detected might be constant or first manifested themselves only during complicated gait (closed eyes, tandem walking, running). Fallings were the most frequent posture disturbances. An attention was drawn to phenomena indicative of involving environment of patient in symptom (pushing of furniture, falling on the physician) and to involving the means of nonverbal communications (space-touching hands, flailing arms, suffering facial expression etc). Phenomena revealed as a result of our investigation could be used in diagnostics of psychogenic gait and stance disorders.

[Autonomic regulation in patients with panic attacks based on longitudinal study data on the variability of the heart rhythm]. / Vegetativnaia reguliatsiia u bol'nykh panicheskimi atakami po dannym longitudinal'nogo issledovaniia variabel'nosti ritma serdtsa.

During a repeated study in recumbent position as well as during 48-hour monitoring of the indices of variability of RR intervals of ECG (MDRR) in patients with panic attacks (PA) a stable dominance of VLF (0.07-0.01 Hz) and rigidity of the spectrum typical for patients with panic attacks (PA) in period between the attacks was found. Prevalence of fear emotions as well as accompanying hypothalamic insufficiency were also associated with a decrease of HF. In prodromic period, in attack and after it, there was no dynamics in the frequency of heart's contractions, but there was a sharp increase of MDRR. In prodromic period VLF and LF considerably increased, while HF decreased. In a moment of a panic attack LF and HF continued to increase, while VLF significantly lowered. Activation of vasomotor (LF), vagal (HF) and cerebral (VLF) mechanisms was maintained during 5 minutes of the study after PA completion with a clear predominance of LF component.

[New approaches to diagnosis of hysteria]. / Novye podkhody k diagnostike isterii.

Postural stability or fluctuation of general centre of gravity (GCG) was investigated in 14 patients with hysteric motor disorders(alterations of statics and walking, pseudopareses) by means of stabilograph. Comparative groups included 7 patients with hemipareses of vascular origin, 7 patients with multiple sclerosis with spastico and atactic disturbances and 7 healthy individuals. The amplitudes of GCG fluctuations in both sagittal and frontal planes as well as their correlations were analysed. It was shown that amplitude of GCG vibration was maximal in hysteriac patients. However patterns of regulation of postural control in hysteriac patients (correlation of amplitudes of vibrations in sagittal and frontal planes) were similar to those of healthy individuals and differed significantly from organic models.

[The efficacy of alprazolam in the therapy of panic disorders]. / Effektivnost' alprazolama v terapii panicheskikh rasstroistv.

22 patients with panic disorder (diagnosis according to ICD-10) were treated with alprazolam (monotherapy) in a dose of 1-2,5 mg/daily during 6 weeks. Disappearance of panic attacks was observed in 59% of cases while in 27% of patients they arose more rarely. The drug's antipanic action was revealed during second week of treatment. The side-effects were typical for benzodiazepine preparations. No one patient refused of drug administration in connection with side-effects development. Prognostically unfavourable signs were found: the high frequency of panic attacks, the presence of atypical marked permanent symptoms in attack structure, as well as the steady vegetative disturbances presence.