Lviv Clinical Bulletin

8-14

Authors: Denesiuk O., Denesiuk V., Mostovoy U., Tsherbak V., Danil’chuk I., Rasputin V., Sergiychuk O.

Introduction. The study of the effectiveness of treatment of acute myocardial infarction (AMI) with comorbide arterial hypertension (AH) is an actual problem of the modern cardiology. According to the statistics of 2010, 8.6 million of Ukraine’s population suffer from the coronary heart disease (CHD), the AMI occurs in 50 thousand of these patients annually. Hypertension affects more than 12 million people. The question of the effectiveness of coronary stenting in patients with AMI and comorbide AH is insufficiently studied. Aim. To analyze the results of the effectiveness of coronary stenting in patients with AMI with comorbide AH. Material and methods. The inclusion criteria in the study were patients with Q–IM, Q–IM and comorbide hypertension, complicated by lesions of the organs of the circulatory system. The exclusion criterion was the age over 80 years, heart failure (HF) of the functional class IV, neoplasms, severe kidney and liver diseases. Results and discussion. A retrospective analysis of the medical records of 105 patients with AMI with comorbide hypertension who were undergoing treatment in the cardiology Department N 1 of the clinical hospital N 1 in Vinnytsia from 2011 to 2014. Acute Q–IM with elevate ST-segment was observed in 84,8 % of patients, acute not Q–IM with elevate ST-segment – in 15.2 %, acute anterior Q–IM – in 39.0 %, inferior Q–IM – in 42.9 %. Repeated myocardial infarction in the anamnesis was observed in 14.2 % of patients. The average age of patients was 56.7 ± 0.80 years. Patients got into the infarction department up to 3 hours after the occurrence of AMI in 39,0 % of cases; in 4–6 hours – in 18.1 %; in 7–24 hours – in 20.0 %; in more then 24 hours – in 22.9 %. The duration of AH in anamnesis was 9.0 ± 0,45 years, chronic CHD – 2.8 ± 0.25 years. In examined patients the values of systolic blood pressure was 138.0 ± 2.15 mm Hg, diastolic – 89.4 ± 1.27 mm Hg. The examined patients underwent the general blood analysis, determination of the lipid spectrum of blood, troponin I and T, ECG. Angiographic examination was performed using the Siemens Axiom Artis (Germany) for 2-3 hours after hospitalization of the patients. In the unit of resuscitation and intensive care cardiology Department N 1 for patients with AMI and comorbide AH was administered pain medication, were prescribed dual antiplatelet therapy, beta-blocker bisoprolol at a dose of 5.0–10.0 mg/day, ACE inhibitor perindopril at a dose of 5.0–10.0 mg/day and lipid-lowering therapy with atorvastatin at a dose of 20 mg/day. Examined patients with AMI with comorbid hypertension often experience such cardiovascular complications: heart failure of І-III NYHA functional classes – in 100 %, acute left ventricular insufficiency of І–III of classes according to the classification of T. Killip, J. Kimbal occurs in 19.0 %, arterial fibrillation in 7.6 %, ventricular extrasystoles II–V grades in Launam – in 7.0 %, ventricular fibrillation – in 3.8 %, cardiogenic shock – in 2.9 percent. One-vascular lesions of the coronary arteries (VA) was observed in 26.7 % of patients, 2-vascular – in 28.5 %, 3-vascular – in 44.8 %, subclause and occlusion – in 57,1 % of patients. Patients with comorbid hypertension were installed one stent in 86.3 % of cases; two stents – in 13.7 %. Restoration of blood flow in the anterior mishloach VA occurred in 58.1 %, the right VA – in 26.7 %, in the envelope VA – in 12.4 %. Failure to restore the coronary blood flow was observed in 2.9 % of patients. Clinical efficacy of restoring coronary flow in patients with AMI with comorbid AH according to the results of the TIMI: TIMI 1 (partial) – 0.9 %, TIMI 2 (significant) – in 20.0 %, TIMI 3 (complete, normal) – in 76.2 %, TIMI 0 (not restarted) – in 2.9 % of patients. Conclusions. 1. Сoronary blood flow in patients with AMI with comorbid AH was renewed in the front interventricular VA in 58.1 % of the patients, in the right VA – in 26.7 %, in the envelope VA – 12.4 %, failed to restore coronary blood flow in right VA – in 2.9 % of cases. 2. Reparation of coronary blood flow in patients with AMI with comorbid AH took place according to the criteria of TIMI 1 (partial) in 0.9 %, TIMI 2 (significant) – at 20.0 %, TIMI 3 (normal) – 76,2 %, TIMI 0 (did not happen) – 2.9 % of cases, which shows the effectiveness of the interventional treatment.

21-26

Authors: Аbrahamovych О., Аbrahamovych U., Tsyhanyk L., Synenkyi О., Romanyuk О.

Introduction. Osteoporosis is one of the most common systemic diseases of the skeletal system that is characterized by decreased bone mass per unit volume, increased bone fragility and risk of fractures. The prevalence of low bone mineral density in patients with systemic lupus erythematosus (SLE) is high, compared to the general population: osteopenia is diagnosed in 25.0–75.0 % of patients with SLE and osteoporosis – in 1.4–68.0 % of patients with SLE. According to the results of prospective studies, it was found that the combination of increases in bone resorption markers or bone formation markers in postmenopausal women with low bone mineral density (BMD) is associated with the increased risk of fractures – by a factor of 2.0–2.5. Aim. To characterize bone tissue in postmenopausal women with systemic lupus erythematosus. Materials and methods. SLE patients were randomized in the study, stratified by sex and postmenopausal status. 71 women (experimental group) aged 47 to 68 years (mean age at the time of the study – 54.08 ± 0.72 years) with SLE diagnosed according to the criteria set by the American College of Rheumatology (1982, 1997) were included in the study. The mean disease (SLE) duration was 13.83 ± 0.97 years; all the women at the time of the study were in postmenopausal status. 100.0 % of the patients received methylprednisolone at a dose of 8.0 to 24.0 mg/day (mean dose – 11.94 ± 0.55 mg/day) and calcium supplements at a daily dose of 1000.0 mg in conjunction with vitamin D supplement at a daily dose of 400.0 IU. The mean duration of glucocorticoid treatment in conjunction with calcium and vitamin D supplements corresponded to the mean duration of disease. The control group comprised 30 almost healthy women aged 49 to 62 years (mean age at the time of the study – 54.67 ± 0.79 years) in postmenopausal status. Two bone formation markers (osteocalcin and P1NP) and one bone resorption biochemical marker (β-crossLaps) were used to assess the rate of bone remodeling. The ultrasound bone densitometry of the calcaneus was conducted in order to evaluate the structural and functional state of bone tissue. The densitometry was performed using the ultrasound bone densitometer SONOST–2000 (OsteoSys Co., Ltd, Seoul, Korea). The statistical analysis was performed using Statistica 6.0 package (Stat Soft Inc, USA). Results and discussion. In all patients with SLE (100.0 %), changes in bone tissue were found: the first stage of osteopenia – in 16 patients (22.5 %), the second stage of osteopenia – in 19 patients (26.8 %), the third stage of osteopenia – in 24 patients (33.8 %), osteoporosis – in 12 patients (16.9 %). Osteocalcin levels were significantly elevated (by 19.76 ± 1.11; p < 0.001) in SLE patients, compared to the control group, and P1NP levels were higher, but not statistically significantly. β-crossLaps marker was significantly higher in patients with SLE, compared to the control group (by 0.15 ± 0.03, p < 0.001). According to the results of ultrasound densitometry, all patients with SLE were divided into four groups depending on the degree of BMD loss: the first group included patients with the first stage of osteopenia; the second group included patients with the second stage of osteopenia; the third group included patients with the third stage of osteopenia; and the fourth group – patients with osteoporosis. Patients of the 1st group had statistically significantly higher levels of bone formation marker – osteocalcin (by 18.94 ± 2.15; p < 0.001) – and bone resorption marker – β-crossLaps (by 0.06 ng/ml ± 0.04, p < 0.05), compared to the control group. Patients of the 2nd group had significantly higher levels of two bone remodeling markers – osteocalcin (by 17.96 ng/ml ± 1.87; p < 0.001) and β-crossLaps (by 0.08 ng/ml ± 0.03, p < 0.01); a lower level of bone formation marker – P1NP (by 3.93 mcg/L ± 1.98; p < 0.05), compared to the control group. Patients of the 3rd group had significantly increased levels of osteocalcin, P1NP and β-crossLaps (by 21.04 ng/ml ± 4.04, p < 0.001; 0.69 ng/ml ± 6.49, p < 0.05 ; and 0.25 ng/ml ± 0.04, p < 0.001, respectively), compared to the group of almost healthy women. Patients of the 4th group had significantly higher levels of two bone remodeling markers: osteocalcin (by 20.38 ng/ml ± 1.8; p < 0.001) and β-crossLaps (by 0.16 ng/ml ± 0.05, p < 0.001), compared to the control group. Conclusions. The results of bone densitometry and the obtained levels of bone remodeling biochemical markers associated with the defects in both osteoblast and osteoclast functions show that all patients with SLE in postmenopausal status who comprised experimental group had indeed changes in bone tissue.

32-35

Authors: Slaba O.

Introduction. Changes of peroxide resistance of erythrocytes as a reflection of the metabolic displacements, relating to the development of inflammation in the periodontal tissues can serve as an informative test for the assessment of the nature of structural and metabolic changes during the development of periodontitis in patients with iron deficiency anemia. Purpose of the study To assess the presence and changes of peroxide haemolysis of erythrocytes in patients with generalized periodontitis combined with iron deficiency anemia. Materials and methods of research. The results of peroxide haemolysis of erythrocytes in 46 women with iron deficiency anemia (the control group) and 41 women without one (the comparison group) were observed. The average age was 38.65 ± 4.64 years. Gingival capillary blood was collected for biochemical studies in the morning, the patients were fasting. Heparin was used as anticoagulant (30.0 units by 1.0 ml of blood). The blood was centrifuged at 2500.0 rpm for 30 min. Methods of variation statistics using the program Statistica for Windows, spreadsheet Excel were used to assess the degree of probability of the results. Results of the investigation and their discussion. According to the results, a decrease of the resistance of red blood cells to peroxide-induced haemolysis with the increasing of the clinical manifestations of generalized periodontitis was observed in groups of the patients with different degrees of severity of generalized periodontitis without any other additional pathology (index of peroxide haemolysis of erythrocytes with prime generalized periodontitis of the I stage was increased by 1.24 times, with generalized periodontitis of the II stage – by 1.51 times and with generalized periodontitis of the III stage – by 1,66 times comparing to the individuals with intact parodontium (11.22 ± 0.9, p < 0.05)). People with generalized periodontitis and iron deficiency anemia lasting up to 5 years had reliable increase (34.0 %) of peroxide haemolysis comparing to the individuals with intact parodontium. In analogical clinical group with anemia, lasting for more than 5 years, percentage of hemolyzed cells was increased comparing to the individuals with intact parodontium (in 52.0 %) and comparing to the previous group (in 12.0 %). Was found the difference between the clinical group with anemia lasting up to 5 years and without one (in 28.0 %). The erythrocytes stability to peroxide haemolysis was reducing in case of the increasing of the disease severity in women with generalized periodontitis and iron deficiency anemia lasting up to 5 years. Duration of anemia influenced on the erythrocytes peroxide resistance reducing. It was found the increase of the percentage of hemolyzed cells – in 94.0 % in relation to people with intact parodontium and in 43.0 % comparing to a certain group of the patients with generalized periodontitis of the II stage and without pathology (p < 0.05). In patients with generalized periodontitis of the III stage and anemia lasting up to 5 years the level of peroxide haemolysis of erythrocytes increased in 86.0 % comparing to the patients with intact parodontium and in 20.0 % in comparison with the control group (p < 0.05). In case of more prolonged anemia in this clinical group the increase of the erythrocytes peroxide haemolysis index was increased more than twice compared to the persons with the intact parodontium and by 1.3 times – respectively to the control group (p < 0.05). Conclusions. According to the results, peroxide resistance of erythrocytes was proved to be diagnostically significant and also within comparative analysis of effects in the development of inflammatory and degenerative processes in periodontal tissues with or without anemia. This is especially useful considering the fact that peroxide resistance of erythrocytes indicates not only on the induction of free radical perioxide processes, but also indirectly reflects disorders of hemorheological characteristics.

42-45

Authors: Musij-Sementsiv K.

Introduction. Preschool age is an important period in the formation of the child. During this age period health and physical qualities are formed. Dynamic monitoring of children development is not only necessary for identification of the individual characteristics of harmonious development, but also it provides the diagnostic criteria for the early detection of the grounds for a more detailed examination and planning of effective preventive measures. Purpose of the study was to assess the relationship of caries of deciduous teeth and physical development of preschool children living in countryside. Materials and research methods. Groups of children were formed in a randomized way according to the age (2–6 years old), to intact and caries affected teeth, and to the different degrees of caries activity (N. V. Bidenko). To assess the physical development (height and body weight) 307 children from countryside (basic study group) and 238 children from town (control group) were examined. Results of the investigation and their discussion. During the analysis of the physical development of children of the basic and control groups it was found that their average indices correspond to the average harmonious development. Children of the basic group of research are a little taller compared with the children in the control group, but the difference is not significant. The indexes of body weight are significantly prevalent in children of the basic research group compared with the children of control group. The greatest difference was registered in children of 3-4 years of age. The three years old children weigh is 15,20 ± 0,16 kg in the basic study group and 14,50 ± 0,16 – in the control group, in four years old children – 17,46 ± 0,25 kg and 16,51 ± 0,25 kg respectively (p <0.05). Analysis of the results of research in age aspect showed that the children of the basic group aged 2-4 years with intact teeth are taller compared with the children with caries-affected teeth. However, in the control group the prevalence of height was detected in two years old children with intact teeth (93,17 ± 0,59 cm to 92,30 ± 0,78 cm), 3-4 years old children are slightly taller than the children with the caries–affected teeth. Body weight of examined children in both groups with caries of deciduous teeth was mostly greater than in healthy children. The most significant difference in body weight was observed in 3-5 years old children of the basic group. According to the analysis of physical development the growth of weight was detected in children with different degrees of caries activity. The greatest weight had children with the II and III degree of activity of caries process. The most significant difference in body weight was found in children aged 4-6. A similar trend was observed in the height of the examined preschool children. Children with the II and III degree of caries activity are taller than the children with the I degree of caries activity. The most significant difference in height was found in children aged 4-6. Conclusions. Evaluating the results, children living in countryside are slightly taller and have more weight compared with the children living in the city, especially in the age of 3-5 years. The most significant difference in terms of body weight and height is observed in children with the intact teeth and teeth affected by caries in basic study group. Analysis of anthropometric data in children of basic study group which depends on the activity of caries of deciduous teeth indicates that with increasing of the degree of carious lesions the weight and height in examined children increases as well. The most significant differences were found in children aged 4-6 years. Therefore, according to the results of research, the relationship of caries of deciduous teeth and physical development of preschool children living in countryside is observed quite informatively.

51-54

Authors: Mashura H., Hanych T.

Introduction. Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases where its frequency in the population varies within 3.0–40.0 %. Pathogenesis of nonalcoholic fatty liver disease has a close relation to the components of metabolic syndrome, insulin resistance, abdominal obesity, dyslipidemia and hypertension. In 14.0–20.0 % NAFLD is combined with the defeat of the cardiovascular system, including essential hypertension. The long course of nonalcoholic fatty liver disease in combination with essential hypertension can negatively affect the patient’s quality of life. Purpose of the study is to find out the features of quality of life in patients with nonalcoholic fatty liver disease in combination with essential hypertension. Materials and research methods. We investigated the quality of life of 38 patients with nonalcoholic fatty liver disease combined with hypertension (research group) and in 36 patients with isolated nonalcoholic fatty liver disease (comparison group). The control group included 20 healthy individuals. Assessment of quality of life was performed using the Ukrainian version of the questionnaire Medical Outcomes Study Short Form 36 (MOS SF-36). Results of the investigation and their discussion. Accession to nonalcoholic fatty liver disease of hypertension significantly aggravated the quality of life compared to the quality of life of patients with isolated nonalcoholic fatty liver disease (p < 0.05). Conclusions. The quality of life of patients with nonalcoholic fatty liver disease is significantly reduced. Accession to nonalcoholic fatty liver disease of hypertension significantly affects the quality of life of patients which is manifested as a decrease of physical condition (especially role-functioning caused by physical condition, pain intensity and overall health) and mental health (especially the vitality and social functioning). This is reflected by decrease in parameters of physical and psychological health. It is necessary to consider this factor in treating patients with this pathology.

61-64

Authors: Nehrych T., Papish M., Shorobura M.

Introduction. Amyotrophic lateral sclerosis is a slowly progressive degenerative polyetiological incurable disease of the central nervous system which causes muscle paralysis and atrophy due to the degeneration of the upper and lower motor neurons. As the disease doesn’t usually affect cognitive abilities, the patients are aware of the progressive loss of function and may become irritable and fall into depression. Dependence on other people is a psycho social reason of unbearable suffering, forcing patients to ask a doctor to hasten their death by means of euthanasia or physician-assisted suicide. A possible explanation for the high proportion of euthanasia in patients with amyotrophic lateral sclerosis may be the lack of palliative alternatives. That is why the prospective studies are needed to explore possible links between palliative care, the role of a doctor, quality of life, patient’s motivation and end-of-life medical decisions of these patients. Purpose of the study. To analyze the studies published until now on euthanasia and physician-assisted suicide in patients with amyotrophic lateral sclerosis and to describe the clinical case of those patients alternative supervision tactics. Materials and research methods. We have worked on previous years clinical research data and analyzed a case of the disease of a particular patient who was under our observation. Results of the investigation and their discussion. The percentage of patients who choose euthanasia and physician-assisted suicide is 20.0 %, 17.0 % of them choose euthanasia, 3.0 % – physician-assisted suicide. The most important reasons for requesting euthanasia were: fear of suffocation (45.0 %), dependence (29.0 %), loss of dignity (20.0 %), shortness of breath / difficulty of speech (16.0 %), fear of dependence (14.0 %), (45.0 %), dependence (29.0 %), loss of dignity (20.0 %). The stage of disease and a degree of disablement (arm and leg movements and a language function) at the moment of physician-assisted dying comparing with euthanasia were evaluated. In the late stages of the disease patients tend to choose euthanasia more often while physician-assisted suicide occurs in the early stages. Proper information for the patients about the decrease of possible dying due to suffocation and the ways to prevent that can lessen their fear, ease their suffering and have impact on the high euthanasia rate. If the desire for death is caused by despair, religion can help to lessen it. Continuous deep sedation is relatively common among patients with amyotrophic lateral sclerosis and appears to become an alternative to euthanasia and physician-assisted suicide. The countries where euthanasia is not legal prefer noninvasive ventilation. Research on influence of cyclosporine A on transgenic mouse model with amyotrophic lateral sclerosis discovered that it extends life of mice with this disease comparing with the control group. That discovery aims to influence the function of mitochondria in patients with amyotrophic lateral sclerosis and may be important for extending human life. According to our experience, treatment with riluzole, psychological help, family support help to improve psychological state of patients, reduce anxiety, depression and prevent choosing euthanasia. Conclusions. According to the information obtained by retrospective analysis of the studies, published by 2015, the proportion of the patients who choose euthanasia and physician-assisted suicide is high and amounts to 20.0 %. But our clinical experience shows that by applying riluzole, lessening despair and having back hope for life with the help of religion and psychological support of relatives and doctors, patients can avoid choosing euthanasia and physician-assisted suicide.