Lviv Clinical Bulletin

8-13

Authors: Abrahamovych M., Tolopko S.

Introduction. Liver cirrhosis (LC) as a social and medical problem for a long time does not lose its relevance. The main cause of death of the hepatological patients – comorbid syntropic disorders of other organs and systems, including the respiratory disorders, have for them decisive prognostic value. In the pathogenesis of syntropias there are involved a number of mechanisms, including metabolic disorders, among them – the changes of acid-base balance (ABB), followed by the appearance of the endothelial dysfunction and the opening of arteriovenous shunts, which is the basis of the so-called functional and anatomic substrate of the disorders of other organs. Keeping the sustainability of ABB in a fairly narrow range is one of the conditions of the organism functioning, and is provided by the result of the coordinated efforts of a number of systems, that have arisen evolutionarily. ABB, in its turn, affects the penetration of biological membranes, mobility and sensitivity of the membrane receptors, provides the direction and intensity of the metabolic processes, determines the properties of proteins and colloids, the ability of hemoglobin to bind and give oxygen. That’s why the aim of our study was to investigate the state of the ABB in the patients with LC, its role in the pathogenesis of the lesions of the respiratory system, depending on the severity of LC according to the criteria of C. G. Child – R. N. Pugh. Materials and methods. Into a study, using randomized principle, with the preliminary stratification by the presence of respiratory dysfunctions, not caused by the congenital defects, hereditary diseases of the respiratory system, infectious, autoimmune, allergic, intractable, toxic and professional factors, as well as with the level of SaO2 96,0 % and lower, were included 80 patients with LC [23 women (28.75 %) and 57 men (71.25 %) aged 27 to 73 years], who were hospitalized, examined and treated at created on the basis of the Department of Internal Medicine N 1 of Lviv National Medical University and Gastroenterological Department of Lviv Regional Clinical Hospital, Lviv Regional Hepatological Center. The control group was consisted of 15 healthy individuals identical by the age and gender. For all the patients was performed a comprehensive clinical-laboratory and instrumental examination of all the organs and systems of organs, according to the requirements of the modern medicine and the study of the ABB of blood, including its electrolyte composition through the taking of 1.5 mL of venous bloo, using the syringe with heparin with subsequent analysis of it, using “Analyzer of ABB of blood EC-60” (company “Kverta-med”, Ukraine) with the obligatory consideration of the hemoglobin level, body temperature of the patient, the oxygen content in the air. According to the criteria of C. G. Child – R. N. Pugh the group of compensated liver cirrhosis (class A) was consisted of 20 patients (25.0 % of the examined patients), subcompensated – 30 (37.5 %) patients (Class B), decompensated – 30 (37.5 %) patients (Class C). According to the results of our study can be seen the tendency of negative dynamics of the indices of the partial pressure of CO2, bicarbonate, standard bicarbonate, excess of the bases in the blood and extracellular fluid, buffer systems, K+ and Na+ levels in patients with LC and their dependence on the severity of the disease according to the criteria of C. G. Child – R. N. Pugh. In all the persons of the diagnosed group there was the intensive reduction of these indices, compared with the reference rates (p < 0.05), indicating the presence of metabolic acidosis, which contributes to the appearance and increase of hypoxemia, leads to the changes in vessels receptors sensitivity to the effects of the vasoactive substances. The reduction of their level in blood of the patients directly proportionally depends on the severity of the disease, and the metabolic disorders can be considered as one of the pathogenic mechanisms in the appearance of syntropic comorbid respiratory disorders, which have a decisive prognostic value and is the leading cause of death of the hepatological patients. Conclusions. The indices of ABB, in patients with liver cirrhosis, were significantly lower (p < 0.05), compared with the reference indices, that help to consider identified metabolic disorders as one of the pathogenic mechanisms of the syntropic comorbid lesions of the respiratory system due to the reduced ability of hemoglobin to bind with oxygen, the lost sensitivity of vascular receptors to the effects of the vasoactive substances, followed by the appearance of the endothelial dysfunction, contributing to the rise of dyspnea and hypoxemia. Deteriorating of the values of ABB directly proportionally depends on the severity of LC, according to the criteria of C. G. Child – R. N. Pugh, and manifested as progressive metabolic acidosis with altered gas composition of blood, which is one of the diagnostic criteria for occurrence of respiratory failure.

19-21

Authors: Kiladze M., Katsitadze A., Abrahamovych L.

Іntroduction. Alopecia areata is the most frequent cause of inflammation-induced hair loss, affecting both children and adults and hair of all colors, but historically it has been more prevalent in the younger age groups. It is a recurrent, nonscarring hairloss considered to be an autoimmune process. Although alopecia areata is one of the most common autoimmune diseases, the pathobiology of disease is not fully understood, but there are claims that imbalance of trace elements may trigger the onset of this disease. The aim of the study was to assess the level of some trace elements in the hair of patients with alopecia areata and to propose some methods of correction of the identified deficiency. Materials and methods. In this study were enrolled 23 patients with single patches of hair loss and 1 with subtotal variety in the age from 20 up to 30 from the same two geographical zone, all of them were females. All patients were subjected to full history taking, all cases were clinically diagnosed as typical lesions of alopecia areata. The samples of the hair, approximately about 1 g, were obtained from 4-5 places of the occipital area of the scalp and studied by x-ray fluorescent spectrophotometer. Features of microelement status were based on the determination in the hair of 28 elements divided in three groups – essential (Ca, Zn, K, Fe, Cu, Mn, Cr), additional (S, Br, Cl, Co, Ag, V, Ni, Rb, Mo, Sr, Ti) and toxic (Ba, Pb, As, Hg, Cd, Sb, Zr, Sn, Bi). In accordance to the received data all patients were treated orally in order to correct the imbalance of trace elements and Chophitol, topically all of them were treated by mesotherapy method with soluble trace elements (Mesosystem S. A. and Mesoestetic (Spain)). Injections in the areas of hair loss were made once in 5 days and with physiotherapy -D’Arsonvalization with soluble trace elements (Labcatal) once a day during 10 days course. Results. The course of treatment was individual, the period of observation was within one year, but control visits each month. The therapeutic effects were evaluated through the extent of vellus hair and terminal hair regrowth on the scalp. We graded the therapeutic effects in four varieties: 1) marked recovery: cosmetic satisfaction or terminal hair regrowth of more than 60.0 % on the hair loss patch; 2) partial recovery: terminal hair regrowth less than 60.0 % on the hair loss patch and 3) poor recovery: only vellus hair regrowth on the hair loss patch; 4) no recovery. By the end of the first month of treatment in most patients (67.0 %) was observed abundant growth of lanugo, over the next three months – the growth of long pigmented and non-pigmented hair. In all the observed cases by the end of 3 months of treatment there was significant improvement, lesions decreased in size, the fuzz gave way to a growth of long hair, depigmented hair gave way to pigmented. In 89.0 % of cases the 4-5 month foci of alopecia was closed completely, in 11.0% of cases the complete closure of the lesions took another 2 months. Within one year observation no case of recurrent hair loss was fixed. Conclusions. The present study suggests that trace elements supplementation could become an adjuvant therapy for the AA patients with their low levels and for whom the traditional therapeutic methods have been unsuccessful. Mesotherapy with its principle of minimal doses of drugs provided to the right place is an effective method of treatment and allows to achieve the lasting positive results with the restoration of the thickness and quality of hair.

28-33

Authors: Kostitska I.

Introduction. Diabetes mellitus (DM) is considered to be one of the most serious problems in internal medicine due to multiple organ lesions and irreversible changes in the functioning of the organism. At present, despite the continuous advancement in medical science pathogenetic mechanisms of the development and progression of gastrointestinal form of autonomic neuropathy, particularly one of its manifestations – diabetic gastroparesis (DG) remains insufficiently studied. Purpose of the study. In the scientific literature there are insufficient data on the clinical efficacy of itopride hydrochloride in patients with impaired motor-evacuation function (MEF) of the stomach. There are no answers to the questions about pathogenetic mechanisms of possible effects of prokinetics on the parameters of glycemic control, the incidence of hypoglycemic events, the progression of gastrointestinal manifestations, etc. Therefore, the objective of the research was to determine therapeutic efficacy of itopride in treatment of gastroparesis considering the state of carbohydrate metabolism in patients with type 2 diabetes mellitus. Materials and research methods. To clarify the relationship between the results of itopride hydrochloride therapy and the dynamics of changes in carbohydrate metabolism were examined 48 patients with type 2 DM. They were divided into two groups. In addition to the standard 6-week course of pathogenetically grounded therapy patients of Group I (n = 24) received itopride hydrochloride at a daily dose of 150 mg (50 mg three times a day 30 min before their main meal). Patients of Group II (the control group) (n = 24) underwent the standard therapy without using medicines affecting MEF of the stomach. The clinical severity of DG was determined using the questionnaire ″Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index″ (PAGI-SYM), which allows the patient to assess the severity of symptoms by himself. According to the survey (D-ABS) the prevalence and intensity of the hypoglycemic episodes were determined. To assess MEF of the stomach all the patients underwent 13C-octanoic acid breath test. Results of the investigation and their discussion. According to the results of additional methods of examination there was a direct correlation between the mean PAGI-SYM scores and the results of 13C-octanoic acid breath test (r = 0.63 ± 0.03, p < 0.001). There was also a strong direct correlation between the state of compensation of carbohydrate metabolism (НbA1C, %) and the degree of slowing of gastrointestinal motility according to the results of 13C-octanoic acid breath test (r = 0.64 ± 0.03, p < 0.001). Thus, the course of DG depends on the effectiveness of glycemic control. Total PAGI-SYM scores indicated the positive effect of treatment which was significantly different in patients of Group I before (14.21 ± 3.28 points – moderate DG) and after the treatment (7.28 ± 0.9 points – mild DG) compared to the control group. The results of 13C-octanoic acid breath test confirmed the effectiveness of a 6-week course of treatment with itopride hydrochloride at a daily dose of 150 mg (50 mg three times a day 30 min before a meal) with recovery of gastrointestinal motility (according to treatment Т ½ – 98.24 ± 3.14 min, in dynamics Т ½ – 68.32 ± 3.55 min; р < 0.05) in patients of Group I. In patients of Group II (the control group) the normalization of MEF of the stomach after the course of treatment was not observed (before treatment Т ½ – 97.23 ± 2.61 min, after treatment Т ½ – 92.12 ± 0.16 min; р >0.05). Conclusions. The effectiveness of using itopride hydrochloride at a daily dose of 150 mg has been proven. It has been established that it contributes to normalizing MEF of the stomach in patients with type 2 DM and signs of DG as well as achieving better compensation of carbohydrate metabolism of both prandial and postprandial glucose levels. The possibility of using prokinetic agents to prevent the labile course of DM should be taken into consideration.

39-41

Authors: Yarka A.

Introduction. Chronic venous insufficiency (CVI) of the lower extremities is one of the most popular topics both in vascular surgery and the entire practice of medicine. A particular problem arises when it comes to the choice of treatment of CVI in patients with comorbid lesions. Some authors consider it expedient to apply a compression technique for the treatment of patients with comorbid lesions, but life-long use of it has certain disadvantages. This is also indicated by the latest consensus on the treatment of CVI, where the CHIVA method is distinguished as quite effective, but not widely used. The aim of the study was to examine the effectiveness of the method CHIVA in patients with comorbidities. Materials and methods. In the period from 2011 to 2015 were treated 37 patients with CVI, the selected treatment was CHIVA. The average age of patients was 78 years. Operations were carried out under the local anesthesia. Results and discussion. In all the patients there was observed a regression of signs of CVI. 23 (62.1 %) patients achieved a stable cosmetic effect when observed for 3 years. In the postoperative period the recurrent bleeding from varicose nodes was not observed in any of the patients. Paresthesia in the cut places was observed in 14 (37.8 %) patients, subcutaneous hematomas were observed in 3 (8.1 %) patients. The thrombosis of saphenous veins without signs of inflammation were found by the control ultrasound examination in 11 (29.7 %) patients. Thrombosis of the deep venous system were not observed. In patients with concomitant diseases the systemic complications and exacerbations of the main chronic diseases in the early postoperative period were not observed. By applying the CHIVA surgery procedure, we did not try to achieve a quick cosmetic effect, as is the case with the use of classical methods of surgery and other non-invasive interventions. The goal of CHIVA’s low-invasive operations is to achieve a reduction in pressure in the superficial venous system, which is the main pathogenetic mechanism of occurrence of CVI and causes undesirable consequences of this disease. Transversal venous outflow from the source of pathological reflux allows you to achieve the goal. According to our study, the overwhelming majority of patients treated with CHIVA were elderly and had severe comorbid lesions, which posed a risk for the use of a classic surgical intervention in the presence of CVI. In some patients, deformation of the trunk of the large subcutaneous vein and its mouth, as well as pronounced dilation, did not allow for endovascular laser or radiofrequency ablation. Operative treatment was needed because of the presence of severe forms of CWI and its complications. The use of local anesthesia also had a positive effect, since it minimized the medication effect on the body, made it possible to maximally reduce the length of stay of the patient in the hospital. The average length of stay of a patient in a hospital of 1,2 days minimized the occurrence of such a phenomenon as a hospital pneumonia Conclusions. Using the method CHIVA therapy in the treatment of chronic venous insufficiency is a safe and effective method and can be used in patients with comorbidities.

48-55

Authors: Ferko M.

Introduction. Liver cirrhosis is one of the most important and most difficult problems of modern hepatology. According to the statistics, each year liver cirrhosis kills nearly two million people. The question of the relationship of endothelial dysfunction as a vasoconstrictor and vasodilator imbalance, indices of renin-aldosterone system and natriuretic hormone in the blood of the portal system in patients with liver cirrhosis, their importance in the origin and growth of the severity of portal hypertension caused great interest of the specialists of hepatological profile, and sometimes serve as the subject of stormy scientific discussions with the wording ambiguous and sometimes contradictory conclusions. Today we know that endothelial dysfunction is the factor of portal hypertension origin, but the dynamics of plasma concentrations of endocrine regulators, their role in the increase of the severity of portal hypertension are still not fully studied. Despite the high prevalence of the study of pathogenic mechanisms, searching the main “markers” of the severity of liver disorder and their role in the increase of the disease decompensation in patients with liver cirrhosis, the content of endothelium-dependent vasoactive substances of blood plasma, parameters of renin-aldosterone system, natriuretic hormone in patients with decompensated liver cirrhosis, particularly with varying grades of portal hypertension, are studied insufficiently. Therefore, the aim of our study was to determine the content of some endothelium-dependent vasoactive substances of blood plasma, parameters of renin-aldosterone system, natriuretic hormone in patients with decompensated liver cirrhosis and to identify their dependence on the severity of portal hypertension grade. Materials and research methods. In the study, by randomized method with preliminary stratification, were involved 80 cirrhotic patients with varying severity grades of portal hypertension [23 females (28.75 %) and 57 males (71.25%) aged 27 to 73 years (mean age – ( 47,5 ± 10,9) years), mean duration of disease – (6,5 ± 2,7) years], to whom were conducted inpatient examination and treatment in created Lviv Regional Hepatological Center on the basis of the Department of Internal Medicine N 1 of Danylo Halytsky Lviv National Medical University and Gastroenterological Department of Lviv Regional Clinical Hospital. Also there were examined 20 healthy individuals [8 females (40.0 %) and 12 males (60.0 %)) aged 19 to 70 years (mean age – 41,8 ± 4,2 years)], who formed the control group. For all the patients it was performed a comprehensive clinical-laboratory and instrumental examination of all the organs and systems according to the requirements of modern medicine and improved by us doppler-floumetric ultrasound examination of the abdominal cavity vessels, using our patented method. With the aim to study the contents of some endothelium-dependent vasoactive substances, indices of renin-aldosterone system and natriuretic hormone of blood plasma in patients with decompensated liver cirrhosis, we determined the levels of endothelin-1, cyclic guanosine monophosphate, tumor necrotizing factor α, renin, aldosterone and natriuretic hormone – according to the standardized methodology. According to the results of non-invasive ultrasound dopler-floumetric examination of the abdominal cavity vessels and determining the severity of portal hypertension grade, all the patients were stratified into three groups: the 1st group (portal hypertension of the I grade) included 20 patients (25.0%), the 2nd group (portal hypertension of the II grade) – 30 patients (37.5 %) and the 3rd group (portal hypertension of the III grade) – 30 patients (37.5 %). Results of the investigation and their discussion. According to the results of our study, we can observe the dynamics tendency of the content of endothelium-dependent vasoactive substances, indices of renin-aldosterone system, natriuretic hormone of blood plasma in patients with decompensated liver cirrhosis and their dependence on the severity of portal hypertension grade. In patients with decompensated liver cirrhosis there were observed intense increase of endothelin-1, cyclic guanosine monophosphate, tumor necrotizing factor α, renin, aldosterone and natriuretic hormone compared with the reference rates (p < 0.05), which allows us to consider them as one of the “markers” of the severity of chronic diffuse liver disease. Growth of the level of endothelium-dependent vasoactive substances, indices of renin-aldosterone system, natriuretic hormone in the blood plasma of patients are directly proportional to the severity of portal hypertension grade. This fact indicates, that they are the pathogenetic link in origin and play a key role in the increase of the severity of the leading syndrome of portal hypertension, which causes the worsening of the general state of these patients, leads to a significant decrease of life quality and its complications, including bleeding from varicose esophageal varices, are of the decisive prognostic value and is the leading cause of death of the hepatological patients. Conclusions. In patients with decompensated liver cirrhosis the content of endothelium-dependent vasoactive substances of blood plasma, parameters of the renin-aldosterone system, natriuretic hormone were significantly higher (p < 0.05), compared with the reference indices, that can be considered as one of the “markers” of the severity of chronic diffuse liver diseases. Growth of the content of endothelin-1, cyclic guanosine monophosphate, tumor necrotizing factor α, renin, aldosterone and natriuretic hormone in the blood plasma of patients was directly proportional to the severity of portal hypertension diagnosed using noninvasive ultrasound doppler-floumetric improved examination of the vessels of the abdominal cavity, improved by us. Determination of the concentration levels of endothelin-1, cyclic guanosine monophosphate, tumor necrotizing factor α, renin, aldosterone and plasma natriuretic hormone in patients with decompensated liver cirrhosis can serve as a reliable diagnostic subsidiary criteria for the detection of portal hypertension and as one of “markers” of the determination of its severity grade.

56-64

Authors: Abrahamovych O., Fayura O., Abrahamovych U.

Introduction. Researches of the famous scientists proved, that comorbid diseases often worsen the course of the underlying disease and/or lead to its chronicity, cause disability and premature death of the working population, often make inefficient diagnosis and treatment, increase the costs of the health system to provide medical care. According to the research of WHO experts, people under 40 usually have 2-4 diseases, under 60 – there is a “bouquet” of 5-7 diseases, after 70 – 8-10 or more diseases. So-called “polymorbidity” increases from 10.0 % in patients aged <19 years old to 80.0 % in patients aged >80 years old. Materials and research methods. The work analyzes the literature sources, which deal with the study of comorbid diseases and sufficiently thoroughly reflect the current views of the scientists on the issue. Results of the investigation and their discussion. There are many synonyms of the term “comorbidity”, among them, often are used the following: “polymorbity”, “multimorbidity”, “multifactorial diseases”, “polypathy”, “multicausal diagnosis”, “dual diagnosis”, “pluripathology” etc., which complicates the understanding of the problem and minimizes the ability to use scientific achievements in clinical practice. In Ukrainian literature the authors often use the term “bicausal diagnosis” to describe comorbidity when there are two underlying diseases, to describe polymorbidity – “multicausal diagnosis” (three or more pathological conditions in one individual). In English scientific literature the authors often use the terms “comorbid diseases”, “comorbid conditions”. In general, the sources of information, used by the researchers to study the problem of polypathies, were and are medical histories, hospital records of the patients and other medical records of family doctors, of insurance companies, archives of the pensions for the elderly. Comorbidity itself can be interpreted as a random combination of the diseases, different by its’ etiology and pathogenesis such as nosological syntropy, ie natural occurrence of the regular determined diseases combinations in one patient. The main causes of comorbidity are: affected organs anatomical proximity, common pathogenesis, causal connections, combination of the diseases or iatrogenic causes. Among the factors, that influence the occurrence of comorbidity in humans, is a chronic infection, inflammation, involutive and systemic metabolic changes, iatrogenic factors, social status, environment and genetic predisposition, and the main way of the development of comorbid disorders is causal. The appearing of a particular disease leads to functional first, and later – to organic lesions and further – to an increase of nosologies quantity. Despite the large number of studies, proposed definitions and synonyms, standardized terminology and conventional classification of comorbidity, that would greatly help in the study of its problems, until now is missing. Conclusions. Despite many unsolved patterns of comorbidity and lack of the unified terminology, the search for the new variants of combinations of these diseases continues. After all, they can simply be not yet classified syndromal diseases, or vice versa – to be completely incompatible for the appearance and coexistence in one body. This is the key to solve more and more problems for the diagnosis and treatment of the diseases in the field of the practical medicine.