[CLINICAL AND PHARMACOLOGICAL FACTORS INFLUENCING RESISTANCE TO CLOPIDOGREL IN PATIENTS WITH CARDIOVASCULAR DISEASES].

We analysed clinical and pharmacological factors influencing resistance to clopidogrel in 250 patients with cardiovascular diseases during 18 months. It was shown that the risk ofresistance depends on the form of coronary heart disease, carbohydrate metabolism, the AA genotype of CYP2C19*2 and TBS1 genes. The cardiovascular events significantly morefrequently occurred during 12 and 18 months in resistant diabetics and in the patients with an allele lacking the *2/*3 CYP2C9 gene function and AT/TT polymorphism of the thromboxane synthase gene TBS1.

[Improvement of the supply norms for ships carrying combat missions in peace-time].

The authors developed the projects of norms of supplying of ships of Northern Fleet by medical reinforcement groups. Norms are added by the medicals which are in the log-book of pharmaceuticals and necessary for the sudden problems. The third norm is added by the traumatologic set. Modern diagnostic equipment is also added to the norms. The authors came to conclusion that the forehanded planning of requirement of medical supply for medical reinforcement groups allows to create an adequate norms of supplying of medical reinforcement groups in the Northern Fleet.

[Characteristics of the pathogenesis, manifestations and clinical course of psychogenically induced myocardial infarctions].

With the purpose of investigating peculiarities of psychogenically induced myocardial infarction (PIMI) 82 patients with primary myocardial infarction (MI) were chosen as the subjects of the given controlled study and divided into two groups. The main group consisted of 33 patients, the rest 49 formed the control group. The study showed that coronary atherosclerosis was more pronounced in the patients of the main group, among whom cases of exertional angina in past history were more frequent, and who had more pronounced coronary calcinosis compared to the patients of the control group. At the same time, the clinical course of MI in such patients is relatively benign, but it is more often complicated by early postinfarction angina. All this suggests that the pathogenesis of PIMI differs from that of "classic" MI. In particular, PIMI may be associated with the involvement of more distant parts of coronary vessels. Patients with PIMI seem to need to be regarded as having high risk of repeated coronary disasters.

[Unstable angina: tissue-type plasminogen activator inhibitor and other hemostatic factors in aspirin and intravenous heparin administration]. / Nestabil'naia stenokardiaia: ingibitor tkanevogo aktivatora plazminogena i drugie faktory gemostaza pri prieme aspirina i vnutrivennom vvedenii geparina.

In order to assess the influence of oral aspirin (165 mg/day) and intravenous infusion of heparin (1000 U/h) on fibrinolysis in unstable angina we determined plasminogen activator inhibitor (PAI) activity and plasma contents of fibrinogen, antithrombin III, protein C on admission and on day 3 of treatment in a subgroup of 51 patients (25 aspirin, 26 heparin) from double blind randomized comparative trial of aspirin and i.v. heparin. Initial PAI activity was lower in the aspirin group presumably due to later admissions of these patients during the day. By day 3 activity of PAI increased from 13.5 +/- 2.0 to 18.2 +/- 1.93 U/ml, p = 0.018, and from 17.8 +/- 1.83 to 20.2 +/- 2.44 U/ml, ns, in heparin- and aspirin-treated patients, respectively. Fibrinogen level increased from 3.34 +/- 0.15 to 3.95 +/- 0.18 g/l, p < 0.001, and from 3.36 +/- 0.17 to 3.94 +/- 0.17 g/l p = 0.003 in aspirin and heparin groups, respectively. Protein C level was unchanged. A decrease in antithrombin III observed in heparin group (from 115 +/- 3.2% to 98 +/- 3.4%, p < 0.001) reflected specific action of the drug. Neither aspirin no heparin caused changes in hemostatic parameters which may be interpreted as profibrinolytic action. Changes of PAI are unlikely related to antithrombotic treatment and probably reflect its diurnal and "acute phase" fluctuations.

[Factors influencing policy of examination of patients with stable angina pectoris]. / Faktory, vliiaiushchie na taktiku obsledovaniia bol'nykh stabil'noi stenokardiei.

The study was made to evaluate the rate of application of different diagnostic methods in patients with stable effort angina (SEA) treated in the cardiological department; influence of various factors (social, demographic, risk factors, clinical course of ischemic heart disease, associated diseases, internal picture of the disease) on choice by the attending physician of the diagnostic policy. The trial included 49 patients (44 male and 5 female aged 42-73 years, median 63 years) without contraindications to stress tests and without mental diseases. Choice of diagnostic tests (bicycle exercise only, Holter ECG monitoring only, bicycle exercise + ECG monitoring, none of the two) was made by attending physicians. Information on social, demographic, risk factors, clinical features of IHD and associated diseases was obtained in the course of semistructured interview 2-5 days before the discharge from the hospital. The internal picture of the disease was studied by psychometric testing using "Reaction to the Disease Questionnaire". The results were the following: only bicycle exercise, only Holter ECG monitoring were performed in 15 (30.6%) and 19 (38.8%) patients, respectively (95% confidence interval was 17.2-44.0% and 24.6-52.9%, respectively). None of the tests was made in 15 (30.6%) patients (95% confidence interval was 17.2-44.0%). The choice of the physician was significantly influenced by two factors: obesity and internal picture of the disease. The physicians preferred to avoid bicycle exercise conduction in obese patients and patients with hypernosognosia who consider ischemic heart disease a catastrophe and suffer of vital fear and helplessness.

[Clinical aspects of somatic disease and internal course of the disease (heart ischemia and bronchial asthma model)]. / Klinicheskie osobennosti somaticheskogo zabolevaniia i vnutrenniaia kartina bolezni (na modeli ishemicheskoi bolezni serdtsa i bronkhial'noi astmy]

Criteria of subjective severity (SS) and subjective control of the condition (SC) associated with establishment of the disease internal picture (DIP) were determined in 67 patients with verified coronary heart disease (CHD) and 68 with verified bronchial asthma (BA). Essential for SS were: severity of the subjective symptoms, features of the somatic condition debut, the speed of the disease progression. Essential for SC were the following components: effectiveness of self-care, severity of noticeable or ugly symptoms, features of the triggers (attack provokers). SS and SC criteria can be used for differentiation of the interventions to change the patient's attitude to their disease and therapy in the direction of more compliance with the doctor.

[Psychopharmacotherapy of anxiety disorders in patients with cardio-vascular diseases: the use of aphobazole].

Afobazole was administered to 32 patients, aged 18-60 years, with cardio-vascular diseases and neurotic stress-related psychopathologies and somatoform disorders (ICD-10 F40-F45). The drug was assigned in dosages from 30 to 60 mg daily (mean 50 mg) during 6 weeks, along with basic somatotropic therapy. Twenty-nine patients completed the course. Therapeutic efficacy was assessed by the Hamilton anxiety scale (HAM-A) and a subscale of the Global Clinical Impression scale (CGI). The total number of responders was 21 (70%). The improvement began from the 1st week of the treatment and increased to the 42nd day. At the same time, intensity of mental disorders (phobic, somatisized, anxiety-depressive) gradually decreased up to complete reduction. Afobazole was well-tolerated by patients.

[Clinical features of ischemic heart disease and modes of subjective perception of illness]. / Klinicheskie osobennosti ishemicheskoi bolezni serdtsa i vnutrenniaia kartina bolezni.

The sample included 91 inpatients with different clinical forms of ischemic heart disease (IHD) and modes of subjective perception of illness (subjective meaning of illness). Prichard's Reaction to Illness Questionnaire, Hospital Anxiety and Depressive Scale, Rotter's Internal-External Control Scale and Illness Locus of Control Scale (Bevz I.A.,1998) were used on day 14 after admission for qualification of the patient's subjective perception of illness. The following clinical predictors of hypernosognia (inadequately high subjective significance of illness) were revealed: 1) the onset of IHD in midlife (<65 years) with its subsequent fast progression including high incidence of recurrent coronary events and/or congestive heart failure, 2) "typical" and protracted angina pectoris, 3) cardiac arrhythmias accompanying persistent high heart rate (sinus tachycardia, chronic atrial fibrillation, frequent extrasystoles) and defying any self-care, and 4) severe heart failure. On the other hand clinical predictors of hyponosognosia (inadequately low subjective significance of illness) included 1) the onset of IHD in elderly individuals (>65 years) and its subsequent slow progression without recurrent coronary events and/or congestive heart failure, 2) the socalled "anginal syndrome" (lack of angina's coupling with psychical exertion, atypical pain location, inconstant efficiency of nitroglycerin) and silent myocardial ischemia, 3) the paroxysmal cardiac arrhythmias (infrequent extrasystoles, paroxysmal atrial fibrillation, supraventricular tachyarrhythmias) with normal or slow heart rate between the paroxysms and high efficiency of self-care, and 4) mild to moderate heart failure. The findings are discussed in terms of prediction of specific modes of subjective perception of illness and its practical implications for correction of patient's attitude to his/her disease, correction of non-compliance, optimization of therapeutical alliance and use of heart care resources.

[The role of developmental disorders of the respiratory, digestive and vascular systems in pathology of the lungs in children]. / Rol' porokov razvitiia dykhatel'noi, pishchevaritel'noi i sosudistoi sistem v patologii legkikh u detei.

The results of diagnosis and treatment of bronchopulmonary pathology in 680 children were analysed. It was found that besides developmental anomalies of the lungs and trachea, those of the esophagus, mediastinal organs, diaphragm, and the aorta and its vessels play an important role in the pathogenesis of pulmonary diseases in infants and young children. Traditional and special methods of examination must be used in the diagnosis of these developmental anomalies. Timely correction of the developmental anomalies makes it possible to arrest the bronchopulmonary complications which are associated with them.

[A comparative validation of the scale CES-D, BDI, and HADS(d) in diagnosis of depressive disorders in general practice]. / Sravnitel'naia otsenka shkal CES-D, BDI i HADS(d) v diagnostike depressii v obshchemeditsinskoi praktike.

To determine a most precise instrument for diagnostics of depression and a level of its severity, a comparative study of 3 questionnaires: Hospital Anxiety and Depression Scale (d) (HADS(d)), Beck Depression Inventory (BDI) and Center for Epidemiological Studies Depression scale (CED-D) was conducted in 148 patients (91 women, 57 men), aged 46.5 +/- 9.34 years. An analysis of sensitivity, specificity and predictive values of positive and negative results allowed to detect optimal cut off points, distinguishing depressive patients, as follows: = 18 for CES-D, = 12 for BDI, = 0.89 for HADS(d). For all scales, areas under receiver-operator characteristic (ROC) curve (0.97 +/- 0.02, 0.96 +/- 0.02 and 0.94 +/- 0.02, respectively) proved to be comparable. The optimal cut off points for distinct separation between patients with mild and severe depression were detected as = 26 for CES-D, = 20 for BDI, = 10 for HADS(d). The area under ROC curve for CES-D was higher (0.99 +/- 0.01) than those for BDI (0.86 +/- 0.04) and for HADS(d) (0.83 +/- 0.05). The data obtained reveal that the cut off points ascertained in the study reduce a chance of depression under diagnosis. All the scales could be recommended to interns for primary (screening) diagnostics of depression in routine medical care.

[Psychosomatic disorders (clinical picture, epidemiology, therapy and models of health services]. / Psikhosomaticheskie rasstroistva (klinika, épidemiologiia, terapiia, modeli meditsinskoi pomoshchi.

53.6% of the patients of general hospital suffer from psychosomatic disorders (PSD). Two-dimensional (psychologic/ clinical) model of psychosomatic interrelations is presented which proposes the estimation of the influence of both somatic and psychological factors within PSD pathogenesis. The clinical classification of PSD includes 4 types: somatization (somatoform disorders)--organ neuroses--27%; psychogenic (nosogenic) reactions--57%; stress-related exacerbation of the medical illness (symptomatic lability)--14%; exogenous (somatogenic) reactions--1%. Except psychotherapy, PSD treatment demands pharmacological intervention (including tranquilizers, antidepressants, cerebroprotectors and neuroleptics). Pharmacotherapy should be proceeded with the account of both its possible somatic effects and its interaction with conventional medical agents. The results of the follow-up study prove superiority of psychopharmacotherapy over psychotherapy in terms of long-term efficacy. The most effective model of the organization of psychiatric care in PSD clinic is liasion psychiatry (psychiatrist consults and general practitioner treats). Inpatient treatment of non-psychotic PSD patients requires an organization of specialized units within a general hospital.