Lviv Clinical Bulletin

8-13

Authors: Shved M., Prypkhan I.

Introduction. In the patients with angina pectoris, in case of the iodine deficiency, the metabolism processes, hemodynamics and autonomic regulation can often change. Aim. To find out the peculiarities of the changes of the natriuretic propeptide NTproBNP, diastolic function of the left ventricle and heart rate variability (HRV) in patients with stable angina pectoris in combination with subclinical hypothyroidism. Materials and methods. To understand the features of the clinical signs, the changes of the natriuretic propeptide – NT-proBNP, left ventricular diastolic function and heart rate variability (HRV) in the patients with the stable angina pectoris, combined with subclinical hypothyroidism, 2 groups of the patients were observed: 39 patients with coronary artery disease: stable angina pectoris of II-III functional class (FC) and 44 patients with the stable angina pectoris in combination with subclinical hypothyroidism. In addition to the routine laboratory and instrumental examination methods, the levels of NTproBNP, thyroid stimulating hormone (TSH), triiodothyronine, thyroxine and peroxidase antibody concentrations were determined, also echocardiography, ECG Holter monitoring with providing the heart rate variability testing were performed. Results. The feature of the clinical manifestations of angina pectoris in the patients with the reduced function of the thyroid gland (TG) is frequent attacks of breathlessness and rapid fatigue, meanwhile the anginal pain occurs rarely. Besides, the symptoms of hypothyroidism join and worsen the course of the main disease. The level of the NT-proBNP in the examined patients with angina pectoris and subclinical hypothyroidism is 25,08 ± 0,66 fmol/ml and is significantly higher, compared to the patients with no hypothyroidism (14,24 ± 0,51 fmol/ml) and compared to the control group of the healthy individuals (3,91 ± 0,22 fmol/ml). In the patients with angina pectoris, combined with subclinical hypothyroidism, compared to the patients with isolated stable angina pectoris of the appropriate FC, more pronounced disorders of the left ventricular diastolic dysfunction with more frequent detection of the pseudonormal type are recorded. In the patients with the angina pectoris, combined with subclinical hypothyroidism, the value of TP was 2415,70 ± 37,31 ms2, sympathetic-vagal index was increasing till 2,20 ± 0,04, indicating the decrease of HRV and hypersympathicotonia, meanwhile in the patients with angina pectoris and preserved thyroid function these changes were less pronounced and were 3015,90 ± 38,72 ms2 and 2,07 ± 0,05 respectively. Conclusions. The study of changes of the level of NT-proBNP, the state of cardiohemodynamics and state of autonomic nervous system in patients with angina pectoris in case of iodine deficiency is very important due to the fact that the course of ischemic heart disease is significantly altered – clinical signs of angina are sunken, often symptoms of heart failure are present in the foreground, and this is an important aspect for timely and adequate pathogenetic treatment.

19-22

Authors: Tashchuk V., Hrebtiy H. , Omer Muhammad Khuda Bakhsh, Aissaoui Anis

Introduction. Pathological effects of obesity are realized primarily through arterial hypertension, hypercholesterolemia, glucose intolerance, the prevalence of which is increasing among people with excessive body weight. However, numerous epidemiological studies have shown, an increased mortality rate from coronary heart disease and other non-infectious diseases is observed among the people with a low body mass index compared with the patients with an average body mass index. Aim. Finding out the features of structural-geometric, systole-diastolic remodeling of the left ventricle and endothelial dysfunction of the vessels, as an early marker of atherosclerosis, in patients with hypertension and varying body weight. Materials and methods. The study included 119 patients with arterial hypertension stage II, diagnosed according to the recommendations of the Ukrainian Association of Cardiologists (2008), aged 60 to 85 years (on average 75.0 ± 5.9 years). Of these, 45 had concomitant abdominal obesity, 35 – deficiency of body weight, 39 – normal body mass. A determination of the structural and morphological, systole-diastolic parameters of the left ventricular remodeling and vascular endothelial function parameters, endothelium function, using reactive hyperemia (endothelium-dependent vasodilation) and nitroglycerin (endothelium-independent vasodilation) tests was made. Results. Conventionally considered to be a normal reaction is a dilatation of the brachial artery in the case of reactive hyperemia of over 10,0 % of its diameter prior to the test, if it’s value is less or there is a vasoconstriction, it is considered to be pathological. In hypertensive patients with concomitant abdominal obesity the thickness of the interventricular septum and the posterior wall of the left ventricular, the end-systolic size and end-diastolic dimensions as well as the index of left ventricular mass were significantly bigger than in other groups of patients with hypertension, indicating the tendency to develop mainly concentric left ventricular hypertrophy. The changes, detected by the transmitral blood flow analysis, have the same direction in all groups of patients and reflect the formation of the hypertrophic type of diastolic function disorder. However, the intergroup analysis of the diastolic function changes in patients with normal body mass and abdominal obesity showed that most violations of diastolic filling of the left ventricle occurs in patients with concomitant abdominal obesity. Analysis of echocardiographic parameters in patients with deficiency of the body mass showed a tendency to form a concentric left ventricular hypertrophy and diastolic dysfunction of the first type. In patients with low body mass compared to a group of patients with satisfactory weight, there is a significantly smaller left ventricular mass, indicating a slightly lower level of left ventricular hypertrophy and decrease of the deceleration time of the early diastolic filling caused by an increase in myocardial stiffness, which adversely affects the contractility of the heart. Сonclusions. In patients with the second stage hypertension there was observed a significant decrease in abnormal endothelium-dependent vasodilatation of the brachial artery and a decrease of its sensitivity to shift tension, regardless of body weight, although more pronounced in patients with underweight and in patients with the concomitant abdominal obesity. At the same time the endothelium-independent vasodilation in response to nitrates was preserved.

26-29

Authors: Kebkalo А., Reyti A.

Introduction. Doctors of various specialties – endocrinologists, endocrine surgeons, oncologists – pay much attention to the choice of tactics of treatment of small focal forms of thyroid gland. However, despite the tangible progress, the transition to a molecular or genetic level of the diagnosis is a reality of the next decades, but today we should not underestimate the need to improve the existing diagnostic methods. Aim. To find out the informativeness of preoperative examinations and causes of diagnostic errors in patients with thyroid nodes ≤ 1.0 cm. Materials and methods. A retrospective analysis of information from out-patient cards, history of diseases and protocols of operations of randomly selected 1 266 patients operated on thyroid lesions (thyroid nodules up to 1.0 cm) in the surgical department of the Kyiv Regional Clinical Hospital N 1 in 2009-2014 was conducted. The results of the pathomorphological, cytological and ultrasound findings were compared, the sensitivity and specificity of the ultrasound examination and the fine needle aspiration biopsy using the ultasound in a diagnosis of the subsantimetric thyroid nodes, including microcarcinoma were evaluated. The frequency of the erroneous results of the histological and ultrasound diagnostics of the thyroid microcarcinoma were determined. Results. Sensitivity and specificity of commonly used diagnostic methods of thyroid ultrasonography and thyroid gland with the following cytological examination are 73.9, 79.5 and 71.9 and 83.9% respectively, and therefore can not be applied separately for the verification of small thyroid glands. The reason for the diagnostic errors, in our opinion, in each case is a separate, rather than a comprehensive analysis of the results of the survey. Obtaining the informative material from the patients with the nodes less than 1 cm in diameter in the thyroid gland, depends on the concerted actions of the doctor of ultrasound and the surgeon, as well as the correct choice of nodes, which need to point out first. Conclusions. Today, for the early diagnosis of thyroid cancer in sub-arterial nodes, a comprehensive evaluation of the results of ultrasound scans and an aiming thin-blooded aspiration biopsy with the subsequent cytological study of the material are most optimal.

37-40

Authors: Krystopchuk S.

Introduction. For the treatment of complicated peptic ulcer (PU) of gastroduodenal zone (GDZ) gastrectomy (GE) is still preferred, but in 78.3% of operated post-gastrorectomy disease (PGD) occurs, which can be in a form of 17 syndromes-urogenital, immunological, hormonal-metabolic, pancreatic-hepato-biliary, cardiovascular, etc. Due to the demographic crisis in Ukraine, caused by a decrease in fertility, and given the fact that GE is more often conducted to men of reproductive age, the impact of the operation on the state of the genitourinary system (GUS) requires more in-depth study, and the active interest in this problem is fully justified. In isolated cases, there is information that the activation of lipid peroxidation (LP) and weakening of the antioxidant system (AOS) play an important role in the pathogenesis of GUS lesions, but these processes in patients with GUS lesions after GE due to PU of GDZ have not been studied until now. Aim. To characterize the state of LP and the activity of the AOS in men with lesions of GUS after GE due to the ulcer of the gastroduodenal zone (GDZ). Materials and methods. In a randomized manner, 330 men, that 5 years or more had GE due to the complicated PU of GDZ were selected. The stomach resection according to the classic Balroth-I method was performed for 116 patients, according to Bilroth-II in the modification of the Gofmeister-Finsterer-214. In 67 patients, 1/2 of the stomach was cut, in 232 – 2/3 of the stomach, in 31 – 3/4 of the stomach. For all 330 patients clinical, laboratory tests (complete blood count and urinalisys, Zimnitskiy urine test, Nechyporenko urine test, urine sterility and sensitivity to antibiotics test, Reberga – Tareyev test, levels of creatinine and urea, basal concentration of testosterone in blood serum and instrumental examination (ultrasonographic examination of the urinary system, chest x-ray, radionuclide renography, scintigraphy, excretory urography, cavernosometry,cavrnosography, biostesiometry) were made. To verify the diagnosis the consulting of urologist and sexologist have been received. The treatment was carried out in the therapeutic department of Lviv Regional Clinical Hospital during 28-30 days. Results. It was found, that in late terms after GE due to the PU of GDZ in men with erectile dysfunction and chronic pyelonephritis there is a significant disturbance of LP and antioxidant protection. In most cases, these changes are manifested by the increase of LP, activation of enzymatic antioxidant and decrease of the membrane antioxidant. Conclusions. In our opinion these scientific results will help in the pathogenetic conservative treatment of patients with urogenital lesions after the GE with the application of antioxidants and unsaturated fatty acids.

47-49

Authors: Radchenko O., Bek N., Zvorska I., Mykulynets R.

Introduction. Obstructive sleep apnea (OSA) – a condition accompanied repeated, stop of breathing due to complete (apnea) or partial (hypopnea) narrowing of the airways during sleep at throat and termination of pulmonary ventilation with preserved respiratory effort which appears snoring, reduced partial pressure Blood oxygen, fragmentation of sleep with frequent short-term awakening and daytime sleepiness. Awakening becomes a protective mechanism that activates muscles-dilators of the upper respiratory tract and prevents asphyxiation. Aim. To review the literature on sleep disorders in medical practice of internists, to identify the risk factors of OSA in patients with essential hypertension (EH) and obesity (OB). Materials and methods. A review of literary sources on clinical signs and diagnoses of OSA syndrome was made. We examined 41 patients with EH of the 2nd stage, 1-3rd degree and 1st degree of gynecology. The CG included 27 people (15 men and 12 women) aged 50.2±2.2 years with a body mass index (BMI) 34.0±1.0 kg/m2, with complaints of snoring and sleep disorders. The CG included 14 people (7 men and 7 women) at the age of 47.1 ± 2.9 years, with BMI 31.5±1.1 kg/m2. All the patients were routinely screened according to the Ministry of Health of Ukraine N 384 dated May 24, 2012, and were interviewed by the American Apnea Sleep Association questionnaire. Results. The main symptoms that help to suspect OSA are neurocognitive: pronounced daytime sleepiness, annoyance, weakening of memory and attention, suppression of emotions, apathy, intellectual degradation. The increase of the severity of the syndrome leads to disorders of the cardiovascular system, in particular, increased blood pressure, occurrence of atrial and ventricular arrhythmias. In the main group of surveyed patients, the average score of the questionnaire was 12.6 points. All men and 91.7% of women showed a high probability of sleep apnea (> 10 points). In CG the average score was 7.4 points (p<0.05), and a high probability of sleep apnea was detected only in 3 persons. It is important that EH with OB and snoring were associated with the presence of nodes in the thyroid gland. Moreover, the higher score of the questionnaire means the larger sonographic size of the node. In addition, in the patients from the experimental group were significantly higher waist circumference (108 (102; 110) cm vs. 99 (89; 108) cm, p<0.05), systolic and pulse arterial pressure (160 (160 ; 180) vs 150 (140; 160) mm Hg, p <0.05) and (70 (60; 90) vs 60 (50; 60) mm Hg, p <0.05) than in the persons of the CG, which is evidence of a higher cardiovascular risk in such patients. Conclusions. In patients with EH, stage II, 1-3th degree with OB of 1st degree that were snoring at night revealed very high likelihood of OSA. Snoring is associated with a higher waist circumference, higher levels of systolic and pulsed arterial pressure, and frequent detection of nodular goiter, requiring special attention for internists, cardiologists and endocrinologists.

53-57

Authors: Molodovets O.

Introduction. Interest in the problem of chronic gastritis (CG) is due to the fact that this disease is characterized by chronic course, the severity of which is increasing, gradual atrophy of the gastric glands, the formation of secretory insufficiency, and it is reasonably attributed to the precancerosis. Aim. To optimize the treatment of patients with CG using “Multisal” and “Walnut Greek Tincture”. Materials and methods. Under the dynamic observation, there were 126 patients (51 (40.5%) and 75 women (59.5%)) at the age of 53.3±1.73 years. The diagnose was based on the results of the clinical, laboratory and instrumental examination acccording to th eorders of the Ministry of Health of Ukraine. The material for the study was obtained using a sighting forceps multiple biopsy. The biopsy material was used for histological and cytologic studies. In order to diagnose Helicobacter pylori, a rapid urease test and a cytological method (smear, brush-method) were used. The state of acid-forming function of the stomach was determined using basal topographic pH-metry in all parts of the stomach according to the method developed by V. M. Chernobrov. Results. The results of evaluation of clinical signs of CG dynamics showed that adherence of “Multisal” and “Walnut Greek Tincture” to traditional treatment or their combination contributed to a stable positive dynamics of clinical symptoms in patients with CG, probably, due to the action of proposed treatment. The obtained information allows us to state that based on the results of the evaluation of the dynamics of the macroscopic signs of CG, the treatment complex with simultaneous use besides the basic drugs “Multisal” and ” Walnut Greek Tincture ” is most effective. For all the patients with positive urease test, regardless of the proven treatment it was provided Helicobacter pylori eradication. Conclusions. The adding of “Multisal” and “Walnut Greek Tincture” to the standardized base complex enables to optimize the treatment of CG, improve the subjective well-being of patients, level the endoscopic signs of inflammation of the mucous membrane of the stomach, improve the basal acidity of the stomach, due to the healing properties of “Walnut Greek Tincture”. The obtained results can serve as a basis for their use in clinical practice.