NEUROPROTECTIVE AND ANTIOXIDANT POTENTIAL OF MONTELUKAST-ACETYLCYSTEINE COMBINATION THERAPY FOR BRAIN PROTECTION IN PATIENTS WITH COVID-19 INDUCED PNEUMONIA.

Direct critical attack of the coronavirus on the alveoli and the excessive release of a large number of cytokines (IL-6, IL-1, TNF-α, etc.) provides suitable conditions for the further development of acute respiratory distress syndrome (ARDS) and severe acute respiratory failure. Serious decrease in blood oxygenation often lead to the deterioration of macro- and microcirculation, irreversible brain damage and hence, persistent neurological and mental disorders despite background intensive therapy and adequate respiratory support. Therefore, the aim of our open prospective observational study was to investigate the neuroprotective and antioxidant effectiveness of montelukast-acetylcysteine combination therapy for brain protection in patients with COVID-19 viral pneumonia. A study was performed for five hundred seventy-eight (n=578) outpatients who were tested positive for novel coronavirus (SARS-CoV-2) by nasopharyngeal swap. The median age of patients was 62±17.45 years. In addition to clinical features and RT-PCR results, chest CT and chest X-ray (CXR) with high sensitivity were also very helpful for the early identification of viral pneumonia and COVID-19 disease assessment. Considering the severity of Covid-19 pneumonia and the level of arterial oxygen saturation (transcutaneous hemoglobin oxygen saturation) on room air, all patients were divided into three major groups. Group 1 (n=288) consisted of patients with a mild shift in oxygen saturation (SpO2 ≥ 95%) and well-defined pulmonary lesions (within 1-2 segments) without concomitant diseases; the second group (Group 2, n=250) included patients with clinical manifestations of moderate severity associated with a current saturation of 90-95% (SpO2) and small pulmonary lesions on chest X-ray in the presence of concomitant diseases: arterial hypertension (stage III) or CHF (FC/NYHA-2), coronary heart disease or type 2 diabetes, cancer, tuberculosis, etc. Most of the patients in third group (Group 3, n=48), during imaging studies, showed bilateral lung affection with low and peripheral distribution (with both - either ground glass opacities or multiple pulmonary nodules) and cardiomegaly. The respiratory failure of stage II-III (current oxygen saturation SpO2 75-90%), high respiratory rate (≥25 per minute), hemodynamic impairment (BP≤100/60 mm Hg. Art., heart rate ≥125/min) were the most common objective clinical findings seen in this subset of patients. Laboratory changes included leukopenia less than 4.0x109/L or leukocytosis (≥10.0X109/L). Background respiratory support with low-flow oxygen therapy and combined pharmacotherapy, where, along with montelukast and acetylcysteine, patients were prescribed a cephalosporin, a fluoroquinolone, an antifungal drug, a histamine blocker, an antiplatelet agent, a complex of B vitamins, led to a significant improvement in symptoms and laboratory parameters during the course of the disease. The mean values of the blood biomarkers (CRP - 21.46±4.43 mg/l, LDH - 410.71±40.63 U/l, procalcitonin - 1.08±0.31 ng/ml, and ferritin - 270.43±27.23 ng/ml) return to normal by the 20th day after the fever subsides. Laboratory parameters before and after treatment course showed statistically significant differences between variables (p<0.05). No patient in Group 3 received JAK inhibitors (tofacitinib and baricitinib), IL-6 (olokizumab), IL-17A (netakimab) and glucocorticosteroids, however, recovery rates were completely good. Assessment of the patient's neurological status (based on the NIHSS scores) revealed no signs of neurological changes. Thus, based on the data given, it can be concluded that the high efficacy of the acetylcysteine/montelukast combination (as neuroprotectors) in pneumonia caused by COVID-19 is due to the effect of drugs on key mechanisms of pathogenesis: reduction of oxidative stress as drugs (combination) ensuring the free radical scavenging; stimulation of glutathione synthesis; suppression of cytokine storm; reduction of bronchospasm, mucus secretion and airway edema; lowering of BBB permeability and the ability to improve cerebral microcirculatory perfusion in the presence of antiplatelet agents. In conclusion, the combination of montelukast and acetylcysteine may provide an effective, safe, multicomponent approach to the prevention of hypoxic brain injury in patients with COVID-19 pneumonia.

[EVALUATION OF THE EFFICASY OF THE DRUG OPDIVO (NIVOLUMAB) IN A PATIENT DIAGNOSED WITH UNRESECTABLE SKIN MELANOMA, POSITIVE BRAF MUTATION AND DISEASE DISSEMINATION (CASE REPORT)].

The case was analyzed for response to nivolumab (Opdivo) monotherapy in a patient with recurrent skin melanoma (10x6x6 cm) and disease dissemination (with multiple lung metastasis), positive for BRAF mutation that followed upon the local therapy (surgical excision) and 6 cycles of adjuvant chemotherapy (at CVD regimen - cisplatin, vinblastine, dacarbazine). Histological results: melanoma. Immunohystochemical: S 100-positive; Melan A - positive; HMB45 - positive, AE1/AE3 - negative, p53 - positive in most cells, vim - positive, ɑ sma - weak in most cells, Ki67 - positive in 20%, BRAFmut, ECOG performance status 1, LDH - 1320 U/L (N <308 U/L). The effective treatment available for metastatic or unresectable melanoma, Opdivo (nivolumab) was given at a dose of 240 mg every two weeks. Overall, 5 courses were indicated. Local recurrence of melanoma at the site of the primary excision began to resolve after 3 courses of immunotherapy with checkpoint inhibitor (nivolumab) which led to a significant decrease in the size of the cancer. And 5 courses of nivolumab therapy demonstrated complete regression of local recurrence and multiple lung metastases. No locoregional recurrence was found on MRI of the neck area. The patient's condition is now satisfactory. She doesn't feel pain and refuses to take pain relievers, leads an active lifestyle (ECOG 0). Serum level of LDH is within normal limits. Currently, the targeted therapy with low molecular weight selective inhibitors of mutant BRAF (vemurafenib, dabrafenib) and immune checkpoint blockers (nivolumab, pembrolizumab) is generally recommended for unresectable skin melanoma patients bearing BRAF mutations. Despite this dual treatment strategy, the use of even one nivolumab (in monoregimen), showed complete regression of both - the local recurrence and multiple lung metastases in the case of a positive BRAF mutation and substantially improved the survival of inoperable cancer patient.

[EVALUATION OF NEUROPROTECTIVE ACTIVITY OF COMPLEX IMPACT OF MAGNESIUM OF SULFATE, LAMOTRYGINE AND N-ACETYLCYSTEINE UNDER CONDITIONS OF COMBINED NORMOBARIC HYPOXIA WITH LIGATION OF RIGHT CAROTID ARTERY IN RATS].

Cerebrovascular diseases of ischemic origin still remain the leading cause of death and disability of the population. In acute cerebral discirculation conditions, anaerobic glycolysis is activated, ATP formation rate decreases, the ion pumps work is disrupted and superoxide radicals are formed. Eventually, ionic asymmetry leads to the cytotoxic and vasogenic brain edema. Therefore, it is extremely important to induce simultaneous (complex) effect of medications on the key mechanisms of neuronal damage in process of survival of brain cells during acute ischemic stroke. On this evidence, in the experiments on rats (n=70), the neuroprotective activity of magnesium sulfate, lamotrigine and acetylcysteine as a combination was studied, under normobaric hypoxia conditions (after carotid ligation of the right carotid artery). Researches have shown the use of magnesium sulfate (1000 mg/kg, ip), lamotrigine (20 mg/kg, per os) and acetylcysteine (200 mg/kg, per os) as a combination, is accompanied by increasing antioxidant and neuroprotective activity of drugs. The protective index in this group was 2.18 and the differences were statistically significant compared to control group (p<0.05). All factors - enhancement of the antioxidant systems of neurons by acetylcysteine, inhibition of glutamate excitotoxicity by lamotrigine and correction of ion stress by magnesium ions, critically increase the time prior to apnea. Accordingly, the combination of magnesium sulfate, lamotrigine and acetylcysteine is able to protect brain cells from the damaging effects of oxygen-glucose deprivation and can be effectively used for pharmacological correction of hypoxic brain damage (in acute ischemic stroke).

[FATAL DIAGNOSIS AND THE HORIZON OF HUMAN LIFE (REVIEW)].

The majority of widespread cancers on the stage of clinical manifestation is incurable and therapy is only for the purpose of life extension. So, it isn`t surprising that most of people realize the word "cancer" as a verdict. A man himself doesn`t believe in his own death and doesn`t realize the fact that "Death is an appropriate phenomenon, but not punishment". Facing the death causes existential crisis. The understanding of inevitable fact of death arouses short, but desperate fight against it, which is, in most cases accompanied by anxiety. Some fundamental changes in phsychoemotional status take place within the young patients (knowing the diagnosis), which help an individual move into a new stage of actions with forming new values and aims. All these give conditions for better adaptation of an individual with phsychic traumas. So, the research of a person`s emotional situation, facing the death, will help to indentify the necessity of prophylactic pharmacotherapy with anxiolytics and to overcome both the negative associations with death and the fear connected with it (preserving life horizon).

[Study of bioavailability of paclitaxel after sublingual administration].

The bioavailability of sublingual form of paclitaxel, developed in the pharmacology laboratory of pharmaceutical company - Legion "Provisus" is studied. Sublingual form of paclitaxel is an alcoholic solution of paclitaxel (1 mg/ml) with penetrator - dimethyl sulfoxide (DMSO) addition. Experiments were performed on 180 white mongrel male mice each of 25-30 g. The animals were divided into three groups. The first group served for control. 10 mg/kg of taxol was injected (once) in the lateral tail vein of the first group animals. A solution was prepared by diluting taxol with physiological sodium chloride solution until to a final concentration of paclitaxel to 1 mg/ml. The dose of 10 mg/kg (single dose) was applied under the tongue of the second group animals. Paclitaxel (substance) was extracted with dichloromethane - Taxol (by liquid-liquid extraction) for the manufacturing of a sublingual form. Unlike the second group, the third group animals took the same dose of sublingual form of paclitaxel orally (by gavage). The concentration of paclitaxel in plasma was studied by reversed-phase HPLC with spectrophotometric detection at λ = 227 nm by Woo JS et al. (2003) method. Bioavailability was determined by comparing the concentration of paclitaxel in blood after sublingual and intravenous use of Taxol (as an area under the curve of concentration versus time). It is established that the bioavailability of sublingual forms of paclitaxel was 42.4%, Cmax = 615 ± 73 ng × ml(-1) and tmax = 30-35 min. The value of the initial volume of distribution of paclitaxel (Vd = 3,14 ± 0,85 l × kg(-1)) also shows its intensive penetration to the organs and tissues. The half-life of the drug on the terminal segment of concentration-time curve was averaged 1,06 ± 0,21 h. The results create the preconditions for further preclinical study of sublingual form of paclitaxel, as the bioavailability of paclitaxel after sublingual application allows to have a systemic effect on the tumor process.

[A comparative study of antiarrhythmic and antihypoxic effects of magnesium sulfate, its prolonged form and blockers of calcium channels].

The aim of the study is the comparative study of treatment of heart and brain damages during the hypoxia with magnesium sulfate, verapamil, diltiazem. As a result of the experiment carried out on rats it was proved that magnesium sulfate and its prolonged form are not less active than the blockers of calcium channels, such as verapamil and diltiazem. It is possible to avoid lethal fibrillations caused by calcium chloride with the help of 25% magnesium sulfate solution (after intraperitoneal administration with the dose of 1000 mg/kg) in case we make arrythmogenic injection 5 minutes after inputting magnesium sulfate solution. During the arrhythmia induced by calcium chloride prolonged form of magnesium sulfate is also effective only if we inject the drug subcutaneous 30 minutes before the arrythmogenic injection. If the interval is 5 minutes lethal fibrillations cant be avoided as the release of magnesium ions from the drug form is slowed down. The drugs containing magnesium ions also displayed cytoprotective activity on the model of normobaric hypoxia. This was resulted in the increase of protective index. Neuroprotective action of magnesium ions (in the condition of hypoxia) is caused by maintaining homeostasis of calcium ions and by inhibition of exocytosis of neuromediators in the synaptic cleft. Thus, magnesium sulfate and its prolonged form can be used with the purpose of pharmacocorrection of heart and brain injuries during hypoxic conditions.

[Clomiphene, ovarian hyperstimulation syndrome and pregnancy].

In case of an ovarian hyperstimulation syndrome surgical treatment causes the regress of symptoms much faster than pharmacotherapy--during the resection of an ovary the concentration of estrogenes in blood is effectively reduced. Frequent use of ovulation inductors (Clomiphene Gonadotrop(h)in) is accompanied by ovarian hyperstimulation syndrome. It is characterized by the increase of sizes of ovaries; the formation of ascites and hydrothorax, by the thromboemboly of main blood vessels and etc. Clomiphene accelerates the maturation process of follicles, but contributes to the increase of concentration of oncomarker CA-125 in blood. This makes it difficult to verify the diagnosis of ovary cancer, particularly among pregnants. The case report of infertility treatment with Clomiphene is depicted. Woman became pregnant after three courses of infertility treatment, but pregnancy was complicated with cardiac and lung insufficiency; the suspicion of stage III ovarian cancer aroused. Serious threat to health of a woman resulted in prevention of pregnancy. Right side adnexectomy was conducted. Surgical treatment led to improvement and after four years the patient delivered a healthy child.