[Results of a cohort single-center randomized study of the modulating effect of the drug Mexidol in the rehabilitation of patients who suffered acute cerebral insufficiency]. / Rezul'taty kogortnogo odnotsentrovogo randomizirovannogo issledovaniya moduliruyushchego effekta preparata Meksidol v reabilitatsii patsientov, perenesshikh ostruyu tserebral'nuyu nedostatochnost'.

OBJECTIVE: Evaluation of the effect of pharmacological modulation of the rehabilitation process with the drug mexidol as an adjuvant component of the rehabilitation treatment of cognitive-emotional disorders in patients who have suffered acute cerebral insufficiency (ACI) due to acute cerebrovascular accident or traumatic brain injury. MATERIAL AND METHODS: The study was conducted as a randomized interventional prospective study and consisted of 5 visits. Patients were divided into 2 groups: main (n=30, standard therapy + Mexidol IV 500 mg per day for 10 days, followed by Mexidol FORTE 250 orally, 1 tablet 3 times a day for 8 weeks) and control (n=30, standard therapy for 66 days). RESULTS: The study randomized 60 patients who underwent ACN and received rehabilitation treatment in accordance with regional routing. In the main group, there was an improvement in cognitive functions comparable to the control group (p<0.001, in both groups there was an improvement in the Schulte test «work efficiency¼ and «total execution time¼, according to the MoCA scale (visit 5 - 23.8±2.6 vs 22.9±31, p=0.227). A significant superiority of the main group over the control group was shown in such indicators as a decrease in anxiety (according to the HADS scale) (visit 4 - 2.6±2.4 vs 4.4±2.4, p=0.004), a decrease in the severity of depression (according to the Beck scale) (visit 3 - 7.5±4.5 vs 11.4±5.6, p=0.005). There was a tendency for the main group to be superior in terms of muscle strength (according to the MRC scale (visit 4 - 3.3±5.1 vs 2.1±2.2, p=0.051), level of vital activity (according to the ShRM - visit 5 - 2.9±0.7 vs 3.3±0.6, p=0.053). A statistically significant increase in the level of mobility of patients in the group using the drug Mexidol was proven compared to the control group (the difference in the Rivermead index at the 5th visit was 10.3±2.8 and 8.0±2.8, respectively, p=0.006), the average increase in the Rivermead index by visit 5 (5.4±2.1 vs 3.4±1.6, p<0.001). A decrease in intensive care aftereffects syndrome (ITS) scores was detected in both groups; a statistically significant decrease in the severity of ITS in relation to the previous visit was detected only in the group using the drug Mexidol (p<0.001). In the main group, the best indicators of the dynamics of systolic cerebral blood flow velocity and overshoot coefficient were also determined, compared to the control group. There were no adverse events recorded in the study. CONCLUSION: A positive modulating effect of Mexidol has been demonstrated in terms of accelerating the restoration of tolerance to cognitive loads, improving the psycho-emotional background by reducing symptoms of anxiety and depression, and secondary improving the results of motor rehabilitation in the early recovery period in patients who have undergone ACI, including those with manifestations of PIT syndrome. During the study, no adverse events were recorded, as well as significant differences in vital functions in the study groups, which indicates comparable safety of therapy in the control and main groups.

[Artificial ventilation in patients with stroke: main results of the Russian multicenter observational clinical trial RETAS]. / Iskusstvennaya ventilyatsiya legkikh u patsientov s ostrym narusheniem mozgovogo krovoobrashcheniya: osnovnye rezul'taty Rossiiskogo mnogotsentrovogo observatsionnogo klinicheskogo issledovaniya RETAS.

OBJECTIVE: To analyze the relationship between the characteristics of respiratory support (RS) for patients with stroke and clinical factors with the number and structure of complications, deaths, and length of stay in the intensive care unit (ICU) and duration of artificial pulmonary ventilation (ALV). MATERIAL AND METHODS: The Russian multicenter observational clinical study «Respiratory Therapy for Acute Stroke¼ (RETAS) that enrolled 1289 patients with stroke requiring RS was conducted under the auspices of the All-Russian public organization «Federation of Anesthesiologists and Resuscitators¼. Indications for ALV, the use of hyperventilation, the maximum level of positive end-expiratory pressure, starting modes of mechanical ventilation, timing of tracheostomy, the incidence of protein-energy malnutrition (PEM) and infectious complications were analyzed. The following scales were used to assess the severity of the condition: the National Institutes of Health Stroke Severity Scale (NIHSS), the Glasgow Coma Scale, the Glasgow Outcome Scale (GOS). RESULTS: For the group of patients with a stroke severity of more than 20 NIHSS points, the mortality increase was associated with initial hypoxia (p=0.004), hyperventilation used to relieve intracranial hypertension (p=0.034), and starting ventilation with volume control (VC) compared with starting pressure-controlled ventilation (PC) (p<0.001). We found that the use of the instrumental monitoring of intracranial pressure was associated with a decrease in mortality (p<0.001). The absence of PEM in patients with stroke is associated with a higher probability of a positive outcome (GOS 4 and 5) for the group with NIHSS less than 14 points (p<0.001). Ventilator-associated tracheobronchitis and ventilator-associated pneumonia were associated with an increase in the duration of ALV, the duration of weaning from the ventilator (for ventilator-associated tracheobronchitis) and the duration of stay in the ICU, and also reduced the chances of favorable outcomes (p<0.05). CONCLUSION: The factors associated with increased mortality in acute stroke are: hypoxemia at the start of ALV, hyperventilation, starting ventilation with VC in comparison with starting ventilation with PC, the use of only clinical methods of monitoring intracranial pressure in comparison with instrumental monitoring. The adverse effect of PEM and infectious complications on the outcome in patients with acute stroke has been proven.

[Perfusion-metabolic interaction in acute cerebral insufficiency. ACIPS study Part I. Cerebral blood flow evaluation].

Basic physiological position that metabolic requirements of brain determine perfusion characteristics of cerebral blood flow underlies the definition of syndrome of acute cerebral insufficiency. So there is a perfusion-metabolic interaction (PMI) in brain tissue at every moment. Based on this paradigm we should synchronize measurement of these components in intensive care practice. The goal of ACIPS study (Acute Cerebral Injury Protection System) is creating methodology of monitoring PMI and treatment algorithm based on this monitoring. In this article we present data that volume cerebral blood flow can be assessed by summing volume bloodflows on brachiocephalic vessels measured with triplex ultrasound. Such results are comparable with CT-perfusion results. Both methods can be used interchangeably if difference in -0.6-11.8 ml/kg/min isn't clinical significant.

[Russian multicenter observational clinical study «Register of respiratory therapy for patients with stroke (RETAS)¼: a comparative analysis of the outcomes of stroke]. / Rossiiskoe mnogotsentrovoe observatsionnoe klinicheskoe issledovanie «Registr respiratornoi terapii u patsientov s ONMK (RETAS)¼: sravnitel'naya kharakteristika iskhodov insul'ta.

OBJECTIVE: To analyze the treatment of patients with severe stroke requiring respiratory support, and identify predictors of death. MATERIAL AND METHODS: A multicenter observational clinical study «REspiratory Therapy for Acute Stroke¼ (RETAS) was conducted under the aegis of the «Federation of Anaesthesiologists and Reanimatologists¼ (FAR). The study involved 14 clinical centers and included 1289 stroke patients with respiratory support. RESULTS: We found that initial hypoxemia in the 28-day period was associated with higher mortality than in absence of hypoxemia (in patients with 20 or more NIHSS scores) (76.22% versus 63.45%, p=0.004). Risk factors for lethal outcome: hyperventilation used to relieve intracranial hypertension compared with group of patients who were not treated with hyperventilation (in patients with 20 or more NIHSS scores) (79.55% versus 72.75%, p=0.0336); volume-controlled ventilation (VC) versus pressure-controlled ventilation (PC) (in patients with 20 or more NIHSS scores) (p<0.001); use of clinical methods for monitoring ICP in comparison with instrumental ones (87.64% versus 62.33%, p<0.001). It has been proved that the absence of nutritional insufficiency in patients with stroke is associated with a higher probability of a positive outcome (GOS 4 and 5) in comparison with patients with signs of nutritional insufficiency, for the group with NIHSS less than 14 points (p<0.001). CONCLUSIONS: A group of factors associated with a deterioration in the prognosis of outcomes in patients with stroke who are undergoing ventilation has been identified: hypoxemia at the start of respiratory support, lack of instrumental monitoring of ICP, the use of hyperventilation to correct ICP, ventilation with volume control (VC), as well as the presence of nutritional insufficiency.

[Preliminary results of rehabilitation intervention for the correction of cognitive impairment in patients with multiple sclerosis]. / Predvaritel'nye rezul'taty reabilitatsionnoi interventsii dlya korrektsii kognitivnykh narushenii u bol'nykh rasseyannym sklerozom.

One of the leading symptoms in patients with multiple sclerosis (MS) is cognitive impairment. It often affects aspects of cognition such as learning ability, memory, processing speed, and attention. It has been proven that patients often complain of difficulties in multitasking and choosing the right words. These problems are often underestimated. Various studies show that regular physical activity, mainly aerobic exercise, can potentially improve cognitive function. Positive effects on concentration, memory, and multitasking were described. In March 2019, the Tyumen regional center of MS, together with the clinical Institute of the brain (Yekaterinburg), launched a clinical study of methods for rehabilitation of cognitive disorders in patients with MS. There was a statistically significant improvement in MOCA-test scores, according to SDMT and PASSAT data in the main group of MS patients. Despite a significant improvement in cognitive function, the self-assessment of mental function according to the MSQOL54-MN test in this group of patients did not change. Our preliminary results suggest that a comprehensive and well-controlled training program can improve cognitive abilities in MS patients even after a short course of treatment.

[Polyneuropathy in intensive care patients].

Critical illness polyneuropathy is an acquired critical illness syndrome of neuromuscular problems as polyneuropathy and/or myopathy that is caused by long-term immobilization, clinically manifested by general muscle weakness and a main reason for difficulty weaning from the ventilator. The review gives an update on the history, epidemiology, etiology, pathogenesis, clinical picture, diagnosis, differential diagnosis, course, outcome, prevention, and treatment of critical illness care polyneuropathy.

[Prognostic evaluation of sleep in patients in a vegetative state].

Coma in the genuine sense is a dreamlike state that lasts not more than 3 weeks, thereafter it progresses to a vegetative stage of consciousness recovery, except when a patient has died or regained conscious wakefulness. Among those who have achieved the vegetative state progress to the following stage of recovery: mal consciousness or completely return to the initial cognitive level. Others remain in a persistent vegetative state. The registered cases of the vegetative state is as high as 100 per million population (S. Ashwal et al., 1996). This patient category remains terra incognita even for interdisciplinary analysis by neurologists and reanimatologists. Nonetheless, the emotional and financial support to manage this patient category is high. In searching for prognostic criteria for the outcome of a vegetative state, the authors attempted to analyze sleep, one of the earliest phylogenetic autonomic functions. Based on the hypothesis that the cognitive status cannot be regained if sleep is not recovered, the authors conducted a polysomnographic study in 64 patients. Preserved sleep patterns were observed in 27 (96%) of 28 patients with a good outcome versus 11 (31%) of 36 patients with a poor outcome. It is concluded that it is expedient to incorporate polysomnographic monitoring into the examination protocol for patients in a vegetative state.

[Organization of medical care for patients with cardiovascular diseases].

Morbidity with cardiovascular diseases in Sverdlovsk region has increased nearly twice over 10 years. Cardiovascular diseases are main causes of disablement and death, taking over a half of the total population losses over recent years. The article was aimed to specify approaches to manage risks of population losses with cardiovascular diseases. Structuring main blocks in organization of medical care for cardiovascular patients was attempted.

[The use of music therapy in the treatment of adverse effects in patients with multiple sclerosis treated with alemtuzumab]. / Primenenie muzykal'noi terapii dlya korrektsii nezhelatel'nykh yavlenii pri terapii alemtuzumabom u bol'nykh rasseyannym sklerozom.

Alemtuzumab (Lemtrada) is a recombinant humanized IgG1 kappa monoclonal antibody against cell surface glycoprotein CD 52. It is authorized in more than 65 countries worldwide including the Russian Federation. This is one of the most effective drugs for the treatment of the aggressive form of multiple sclerosis. Its safety profile includes different infusion reactions. Current publication demonstrates our experience of using music therapy during alemtuzumab infusion and its role in the adverse reactions management.

[Cytoflavin as a modulator of rehabilitation treatment of patients with ischemic stroke complicated by post-intensive care syndrome]. / Tsitoflavin kak komponent reabilitatsionnogo lecheniya patsientov s ishemicheskim insul'tom, oslozhnennym PIT-sindromom.

OBJECTIVE: To assess an effect of cytoflavin on the results of rehabilitation treatment and the increase in exercise tolerance in patients with stroke complicated by post-intensive care syndrome (PICS). MATERIAL AND METHODS: The data of 53 patients who underwent neurorehabilitation in the ICU after ischemic stroke were analyzed. Depending on the treatment regimen, the patients were divided into two groups. Group 1 (main, n=36) received cytoflavin (iv drip in a volume of 10 ml of a solution for injections per 200 ml of a 0.9% solution of sodium chloride) for 10 days in addition to the complex of neurorehabilitation measures. Group 2 (control, n=17) included patients, who had only a standard set of neurorehabilitation measures for 10 days. The efficacy of the therapy was evaluated using indirect calorimetry, and the oxygen and energy load price index was calculated. To assess the tolerability of rehabilitation methods, a verticalization test was used. Treatment tolerance was assessed by the incidence of adverse reactions in each group. RESULTS AND CONCLUSION: The components of the energytropic effect of cytoflavin can have a positive modulating effect, increasing the tolerance of rehabilitation measures for the treatment of PICS in patients with ischemic stroke. Further research is required.

[Correction of intracranial hypertension syndrome using hyperosmolar solutions in patients with severe brain damage (multicenter randomized clinical study)].

The paper presents the results of a muticenter study of the effect of 3 hyperosmolar solutions (15% mannitol solution, 10% sodium chloride solution, and the combined solution HyperHAES containing 7.2% sodium chloride and hydroxyethyl starch 200/0.5) on the value of intracranial pressure (ICP) (invasive ICP monitoring) and systemic hemodynamic parameters (PiCCOplus) in 94 clinical cases of intracranial hypertension (ICP more than 20 mm Hg) in 25 patients with acute cerebral pathology (severe brain injury, aneurysmatic subarachnoid hemorrhage). Intravenous infusion of the solutions was found to induce a reduction in ICP; however, this was most pronounced (by 30-40%) and longer (up to 4 hours) when HyperHAES solution was used. This solution produced not only an osmotic, but also hemodynamic effect.

[Use of amantadine sulfate (PK-MERZ) during emergence from coma: results of a multicenter study].

The paper gives the results of the first multicenter study of the efficiency of using amantadine sulfate (PK-Merz) in patients with acute cerebral disease during coma emergence. The study has shown a positive effect of this drug at coma emergence, which manifested itself as clinical improvement and a better outcome of the disease. Full objectivism of the findings requires further studies.

[Acute cerebral insufficiency syndrome as a concept of neuroreanimatology].

The introduction of concepts of acute cerebral insufficiency syndrome into the clinical practice of a number of therapeutic-and-prophylactic institutions raises a lot of questions as to its clinical interpretation and approaches to diagnosing, monitoring, and treating patients who meet its criteria. By attempting to have methodologically adequate solutions of this problem, neuroresuscitators are making a complex scientific developments of reproducible modes of neuromonitoring and cerebrotropic intensive therapy. The theory of acute cerebral insufficiency and a cerebral protection complex becomes an area that determines researches in the development of new methods of intensive cerebrotropic therapy, as well as the ways of neuroreparation and neuroprotection as components of complex pathogenetic therapy for neuropathological syndromes resulting from the formation of pathological systems in response to abnormal determinants.

[The efficacy and safety of telethrombolysis in a newly opened stroke unit]. / Éffektivnost' i bezopasnost' teletrombolizisa pri otkrytii novogo pervichnogo sosudistogo otdeleniia.

AIM: To evaluate the efficacy, safety and limitations of telethrombolysis, stroke consultation by telemedicine, in a newly opened stroke unit. MATERIAL AND METHODS: Thirty-three patients (remote group) received intravenous thrombolysis via telemedicine in a new stroke unit from November 2016 to October 2017. Twenty-two patients retrospectively enrolled in the study received bedside thrombolysis (bedside group). The primary endpoint was the shift of modified Rankin scale (mRS) score at hospital discharge using ordinal logistic regression. RESULTS AND CONCLUSION: There was no significant difference in the scores on mRSscale between two groups. The average score on mRS at discharge was 4 in both groups, the percentage of patients with 0-2 score was 27.3% in the bedside group and 23.5% in the remote group. The rate of symptomatic hemorrhagic transformations was significantly higher in the remote group compared to the bedside group (29.4 and 4.5% respectively, p=0.022) with the similar mortality rate. The implementation of telethrombolysis in new stroke units appeared to be safe and effective. However, further clinical research is needed.

[Nutritional support in critical conditions as intensive care technology].

The patients of intensive care units represent a group in which nutritional support methods, such as enteral and parenteral feeding, are most frequently used to correct protein and energy metabolisms. The purpose of this paper is to analyze the most significant clinical problems ensuing in nutritional support in an intensive care unit, such as the high incidence of hospital exhaustion, difficulties in metabolic monitoring and in the determination of patients' needs for nutrients, in the choice for media for intravenous and enteral feeding, in the prevention of possible complications of nutritional support; organizational aspects.

[A comparison of remote and bedside assessment of the NIH Stroke Scale in acute stroke patients]. / Sopostavlenie prikrovatnoi i distantsionnoi otsenok po shkale NIHSS u bol'nykh v ostreishem periode insul'ta.

AIM: Telestroke videoconference for conducting the National Institute of Health Stroke Scale (NIHSS) is recommended when direct bedside evaluation by a stroke specialist is not immediately available for hyperacute stroke assessment. However, some NIHSS-telestroke studies inherit systematic bias due to subjectivity of NIHSS administration. Authors aimed to evaluate NIHSS telestroke assessment, while implementing measures to minimize subjectivity bias. MATERIAL AND METHODS: Ninety acute stroke patients within 48 hours of onset were assessed by 6 stroke neurologists grouped in 15 pairs. Each pair of physicians assessed 6 patients. Patients were allocated through block randomization to a physician pair and order of bedside or remote assessment. Every patient was assessed once at the bedside and once remotely. Remote examination was performed by a neurologist through high-quality videoconferencing, assisted by a nurse at the patient's bedside. Kappa coefficients and the number of patients with a cumulative difference of ≤3 NIHSS points were calculated to compare bedside and remote measures. RESULTS: Cumulative difference of ≤3 NIHSS points was observed in 85.6% (95% CI 76.6%; 92.1%) cases. Therefore, every fifth remote examination may have been inaccurate. Quadratically weighted κ for total NIHSS score was 0.91 (95% CI 0.87; 0.95). Minimal agreements were for commands (κ=0.46), facial palsy (κ=0.43), and ataxia (κ=0.27). Remote assessments were longer than bedside: 8 minutes (IQR 7; 9) versus 6 (IQR 5; 8), p<0.001. CONCLUSION: NIHSS-telestroke assessment using high-quality videoconferencing in the acute stroke settings is closely matched with NIHSS-bedside assessment but it's credibility for clinical use needs further evaluation.

[Analysis of the effectiveness of emergency treatment of cerebral ischemic stroke in first aid conditions]. / Analiz éffektivnosti neotlozhnoi terapii mozgovogo ishemicheskogo insul'ta v usloviiakh skoroi pomoshchi.

The impact of the delay in therapeutic intervention at the acute stage of the disease on restitution of neurological functions is shown in 493 patients with ischemic brain stroke, admitted to an emergency neurology unit. The regress of neurological symptoms was notable in 62.9% of patients who were treated by the 6th hour since the disease onset. With the therapy instituted after 6 h, the regress was evident in 49.8% of cases. The treatment impact on the restoration of neurological functions was analyzed in 273 cases.

[Main principles of rapid diagnosis and intensive care in emergency states: their realization in expert systems]. / Osnovnye printsipy ékspress diagnostiki i intensivnoi terapii neotlozhnykh sostoianii: ikh realizatsiia v ékspertnoi sisteme.

A retrospective analysis of 543 case histories over 1980-1990 in the town of Yekaterinburg and analysis of published data permitted the authors to single out the signs characterizing the most frequent syndromes requiring urgent intensive care. By either diagnostic value, these signs are distributed into main, accessory, and ruling out. An expert system has been created, making use of the productive-Freimont's approach to representing information on the basis of blurred multiplicities and ambiguous logics. The diagnosis was made by stages: first the main signs were analyzed, determining the severity of patient's status, then (after first aid was rendered) accessory and ruling out signs, which help make the diagnosis more precise. The system was tried in 231 patients, 102 of these with acute respiratory failure, 63 with acute hemodynamic insufficiency, and 66 with acute cerebral insufficiency. Primary diagnosis of the underlying syndrome was correct in 87-89% of cases, of the concomitant syndrome in 92-97%. Repeated evaluations (in 1-3 and 24 h) taking account of the time course of the symptoms and of the results of unsophisticated instrumental examinations increased the share of correct diagnoses to 92-96%.