Lviv Clinical Bulletin

8-13

Authors: Zharinov О., Levchuk N., Ikorkin М., Sychov О.

Introduction. The choice of the optimal strategy for conducting the patients with persistent atrial fibrillation (AF) and the expediency of prolonged antiarrhythmic treatment after cardioversion is highly dependent on the probability of relapse of arrhythmia. The basis of the clinical systematization of paroxysms of AF and one of the most important elements of the algorithm for the management of patients is the criterion of the frequency of episodes of arrhythmia. The processes of fibrosis, electrical perturbation of the atrium and the creation of conditions for circular circulation of the excitation influence a lot on the course and the possibility of the AF persistence. The aim of the study was to determine the role of clinical anamnesis, demographic and a number of indicators of the structural and functional status of the left heart units to predict the conservation of sinus rhythm in patients with persistent AF for 18 months after the cardioversion. Materials and methods. The study included 225 patients (178 men and 47 women), aged 34–79 years, chosen for planned cardioversion. General clinical investigation, ECG, transthoracic and transesophageal echocardiography for detailed evaluation of structure and function of atria and ventricles were performed in all patients. After cardioversion the follow-up investigations were performed every 6 months. In order to restore the sinus rhythm individually, amiodarone, propafenone, etazysin, or their combination with β-blockers, according to the existing recommendations on their application, were used. In 128 cases (56.9 %) an electrical cardioversion was performed to restore the sinus rhythm of the heart. Results. In total, after 18 months the sinus rhythm was maintained in 125 (55.6 %) patients. At the same time, persistent or permanent AF was registered in 100 patients (44.4 %). The age of patients, duration of the disease, heart rate and some left heart structural and functional parameters had independent role for predicting the sinus rhythm maintenance. I.e., left atrium diameter < 45 mm, index of left atrium volume < 50 ml/m2, left ventricular end-diastolic volume < 145 ml, average left atrium appendage ejection velocity ≥ 30 cm/s, absence of spontaneous contrast phenomenon were predictors of the long-term sinus rhythm maintenance. Conclusions. The obtained model is characterized by the high sensitivity, specificity and diagnostic value in the prognosis of maintaining the sinus rhythm of the heart in case of AF.

19-23

Authors: Abrahamovych O., Abrahamovych M., Tolopko S., Ferko M., Fayura O.

Introduction. A problem of the occurrence and course of liver cirrhosis (LC) and its severity increase is one of the most difficult in modern gastroenterology. An important place in the pathogenesis of LC, the course of the disease and its prognosis takes the state of the autonomic nervous system (ANS). It is known that the disorders of the ANS state is one of the pathogenetic mechanisms of the appearance and increase of the severity of LC, due to the exclusion of the central regulatory mechanisms of life processes with the transition to the lowest level – humoral-metabolic, which is an unfavorable prognostic sign. However the features of ANS state f, in spite of its important role in the human organism, are not sufficiently studied. Aim. To find out the ANS state in cirrhotic patients with the different degree of the severity. Materials and methods. In order to assess the state of the ANS we have conducted a comprehensive clinical and laboratory examination of 93 patients with LCand studied its basic functional and dynamic indices: tone, autonomic reactivity, autonomic support of the organism functioning, using the questionnaire of A. M. Wein, clinical criteria of A. D. Solovyov, functional tests: thermal, cold, Tom-Roux, orthoclinostatic and registration of heart rate variability. Results. According to the results of A. M. Wein’s questionnaire, the most often symptoms of the autonomic disorders were met in the patients of C class (by C. G. Child-R. N. Pugh). According to the results of the medical examination, in obedience to the criteria of A. D. Solovyov, the tone of the sympathetic nervous system (SNS) prevailed in all groups of the patients: for the persons of class A – on 30.0 %, B – on 44.0 %, C – on 51.6 % and for the control group (CG) – on 3.0 %, comparing with the tone of the parasympathetic nervous system (PSNS). Consequently, the conducted studies have allowed us to diagnose the disorders of ANS in all the patients with LC, severity of which significantly increases with the disease decompensation. In all the people SNS tone has prevailed with a tendency to hypertone with increasing of the pathological process severity, indicating the activation of compensatory capacity of the organism to maintenance homeostasis in case of portal hypertension. Results, received after the conducting of cold test, testify, that comparatively to the CG, in most persons of class A (91.3 %) hyperreactivity of the ANS is diagnosed more frequently (p < 0.001), that is in 74.5 and 91.3 % of the persons of classes B and C accordingly (p < 0.001). The results of thermal, orthoclinostatic, Tom-Roux’s probes confirm the indices, got during the conducting of the cold test. The results of the thermal, orthoclinostatic and Tom- Roux’s tests were confirmed by the indices, received during the cold test. Also, during the record of the heart rate variability without stress the indices of the general spectral power (TP), in patients of class A (923.4 ± 191.3 mc2/Hz), B (935.9 ± 139.4 mc2/Hz) and C (203.4 ± 301.9 mc2/Hz) were significantly (p < 0.001) lower than in the CG (3243.8 ± 46.2 mc2/Hz). In the patients of class C the indices of TP were significantly lower comparing with class A (p < 0.001) and B (p < 0.001) with the tendency to the decrease with the increase of severity class. It testifies the strengthening of the SNS influence, however not reflect the structure of the organism regulation levels. The results, got during the conducting of the orthostatic test, confirmed the indices, got before the stress. Conclusions. The results allowed us to diagnose the presence of autonomic disorders in 100.0 % of the patients, with the superior effects of the sympathetic part of the autonomic nervous system over the parasympathetic with the directly proportional increase of the neuro-humoral effects according to the severity of the pathological process in the liver. The study of the correlation between the indices of heart rate variability and classes of liver cirrhosis by C. G. Child-R. N. Pugh lets us recommend them to predict the disease course.

30-33

Authors: Hladchenko O.

Introduction. Infectious diseases of respiratory organs in children today are one of the most important problems of pediatrics. According to statistics, acute respiratory viral infections (ARVIs) occupy a leading place in the structure of the morbidity of children. The importance of this problem lies in the fact that 1.0-5.0% of children of early age with acute respiratory infections are accompanied by acute stenotic laryngotracheitis syndrome (ASLS), in case of which the risk of an unfavorable course of the disease is significantly increased in early childhood. Aim. According to the results of a retrospective study, to study the peculiarities of the course of acute stenotic laryngotracheitis in children aged 0.0-60.0 months, which were treated in the Lviv Regional Infectious Diseases Clinical Hospital during 2013. Material and methods of research. The analysis of 391 medical records of children aged 0.0-60.0 months (117 girls and 274 boys) who underwent inpatient treatment in the 1st diagnostic department of the Lviv Regional Infectious Diseases Clinical Hospital, with the diagnosis “Acute respiratory viral infection, acute stenotic laryngotracheitis” from January, 1 to December, 31, 2013. The patients were divided into three groups, depending on the severity of the stenosis of the larynx, which was recorded at the time of the hospitalization of the patients. 104 children with stenosis of the larynx of the 1st degree entered into the first group, 271 patients with stenosis of the larynx of the 2nd degree – into second group, 17 patients with stenosis of the 3rd degree – into third group. For the analysis there were taken the data from the case history, the severity of the condition at the time of hospitalization, results of complete blood count, bacteriological examination of the mucus from the oral cavity, the presence and nature of the complications, and the treatment that was taken. Results The age of children with ASLS, which caused stenosis of the larynx of the third stage, was 36.7 ± 5.91 months. It was significantly higher than the age of patients with stenosis of the larynx of the I-II degree. The results of bacteriological examination of mucus from the upper respiratory tract revealed virtually the same spectrum of isolated microorganisms in patients of I and II, in children of the III group, the microorganisms were allocated much less frequently. The frequency of excretion of bacteria from the upper respiratory tract did not depend on the presence and type of complications that arose in children with acute stenotic laryngotracheitis. The lack of probable interconnections between the changes in the complete blood count and the results of the bacteriological examinations provides the grounds for treating leukocytosis and increasing of the level of bands as a reaction of macroorganisms to stress, hypoxia, possibly with the administration of the high doses of glucocorticoids, rather than bacterial factors. Conclusions. Respiratory complications unrelated to the presence of microorganisms in the upper airways and peripheral blood changes mainly reflect the child’s reaction to stress and treatment with corticosteroids.

36-38

Authors: Slaba O.

Introduction. Despite the progress in the diagnosis and treatment of bronchial asthma (BA), the tendency to increase the incidence is observed in all age groups. Particular attention is drawn to the increase in the incidence of asthma in economically developed countries, where the problem of obesity has become extremely urgent. Aim. Determine the level of adiponectin in the blood of asthma patients and determine the clinical and laboratory and instrumental parameters depending on it. Material and methods. On the basis of the allergological department of the 1-st Clinical Hospital in Lviv, a comprehensive clinical and laboratory examination of 20 patients with asthma (12 men aged 18 to 59 years old and 8 women aged from 24 to 80 years) was conducted. The criterion for inclusion in the study was the presence of clinical symptoms of asthma, instrumental confirmation of broncho-obstructive syndrome daily oscillation and a test with bronchodilator. For all the patients the general examination (complaints, anamnesis, and complete physical examination) and anthropometric examinations: body mass, body height and body mass index (BMI) were conducted. In addition to standard laboratory studies, based on the indicators of complete blood count, leukocyte index of intoxication was determined, the growth of which indicates endogenous intoxication and tissue decay processes. High-speed and volumetric indicators of external respiration were determined using a computer spirograph “Pneumoscreen”. Results and discussion. The median adiponectin in the examined patients with asthma was 114.6 [90.0; 139.1] ng/l. Significantly different values of adiponectin were seen in patients with varying degrees of severity of the disease. Thus, in patients with severe asthma, the lowest level of adiponectin was 83.5 ng/l, which is significantly lower than in the case of light persistent flow (132.3 [111.8; 171.8] ng/l; p = 0.03). Obesity in patients with asthma was accompanied by the lowest levels of adiponectin in the blood. Analysis of the correlation of adiponectin in subgroups of patients with its level below and above the median showed that in patients with lower levels, the adiponectin content correlated with the largest number of clinical, laboratory and instrumental parameters. The process of reducing adiponectin is associated with longer illness and male gender. According to the correlation analysis, in the conditions of the initial higher level of adiponectin it is unfavorable for the course of asthma as a decrease in its content, which is associated with an increase in severity (τ = -0,5; p = 0,049) and the deepening of endogenous intoxication (τ = -0,5; p = 0.049), and subsequent increase in the amount of adiponectin accompanied by systolic and diastolic arterial hypertension (τ = 0.6; p = 0.02 and τ = 0.6; p = 0.03) and tachycardia (τ = 0 , 5; p = 0.04). Conclusions. It was found that the lowest levels of adiponectin in patients with asthma are observed during the severe course of the disease and in case of obesity. Hypoadiponectinemia is often accompanied by a complicated course of asthma and a decrease in both volumetric, and high-speed function respiratory tests.

43-48

Authors: Kuzyk A.

Introduction. Hemangiomas – are tumorlike vessel changes that occur in children starting from an early age and can appear as minor cosmetic defects that sometimes spontaneously decrease, or can cause serious functional disorders or even be a threat to life. As of today the choice of treatment strategy remains controversial. All the methods for the treating of hemangiomas are divided into local (surgical treatment, laser ablation, selective endovascular embolisation) and systemic (corticosteroids, interferon α2a, cytostatics, procoagulants) treatment with a possible combination. However, these methods are not universal and can not always eliminate the threat to life or disability. In 2008, the first results were published on the use of propranolol in the treatment of hemangiomas in young children, which was the beginning of revolutionary changes in the views of the tactics of treatment of one of the most common pathologies of childhood. Aim. To find out the effectiveness of conservative treatment of hemangiomas with non-selective β-blocker (propranolol) in young children. Materials and methods. In this prospective study we have analyzed the effectiveness of treatment of hemangiomas in 43 children at the age 2–19 months with propranolol (daily dose of 1.0-4.0 mg/kg body weight, divided into three doses, with a tendency to hold the dose in the range of 2.0-3.0 mg/kg/day). 28 patients had isolated hemangiomas of the head and neck area. Treatment lasted from 2 to 14 months and is completed in 33 patients. Results. The presence of hemangiomas in early childhood in the phase of proliferation, especially complicated, leading to impairment of vital functions or to the persistent disturbances and significant negative cosmetic effects, is an indication for systemic treatment. The vast majority of patients (41 children) received a positive clinical response: tumor growth stopped, followed by a decrease of it size up to extinction of the tumor with the absence of significant complications. In the vast majority of patients, since the first days of treatment, a positive reaction of hemangiomiomas was observed as a change in color (weakening), diminishing its tension. This tendency was maintained with the highest intensity during the first months of treatment. No violations of the cardiovascular system or glycemic index were detected. In no patient, the side effects were not a reason for the discontinuation of the treatment. These results indicate the high efficiency of treatment together with its good tolerance, high availability and low risk of complications. Conclusions. An early evaluation of the effectiveness of treatment of hemangiomas with non-selective β-blocker propranolol suggests its high efficacy with simultaneous good tolerance.

54-60

Authors: Yatskevych A.

Introduction. Deformation and foot pain are significant causes of the patient’s medical care. The pain in the foot combined with the violation of its structure is the basic indicators for the operational treatment in about one third of patients in orthopedic hospitals. The effectiveness of its treatment is insufficient, there is a tendency to chronization of the processes often followed by relapses. For the effective choice of the treatment metod it is important to determine the cause, pathogenesis, the origin of the pain impulses, and a direct impact on the source of pain. So, there are four groups of lesions of patients following the predominant localization of pain in the foot: with pain in the anterior part of the foot; with pain in the medial part of the foot; with pain in the lateral part of the foot; with pain in the back of the foot. The respective etiological and pathogenetic situations are characteristic for each of these groups. Aim. To characterize the pathogenesis, diagnoses altogether and treatment of pain in the foot. Materials and methods. Content analysis, method of system and comparative analysis, bibliosemantic method of study of the actual scientific researches on the topic of the pain in the foot, its pathogenesis, diagnose algorithm and treatment with the demonstration of a clinical case have been used. Results. Surgical intervention may be used in case of the ineffectiveness of conservative foot pain treatment, which includes reduction of physical activity, treatment of nonsteroidal anti-inflammatory drugs, local administration of glucocorticosteroids, biologic drugs and matching of footwear. In case of conservative treatment, along with anti-inflammatory drugs, sharp stresses on the Achilles tendon, stretching of the calf muscles should be excluded. Local injecting treatment is effective using biologic drugs and glucocorticosteroids, which can be administered exclusively in the vagina, rather than in the tendon. For the insufficient efficacy of conservative treatment, such operations as longitudinal excision of the degenerate shaft of the tendon that preserves its integrity in the absence of thickening and, consequently, stenosis in the vagina, endoscopic dermatitis are recommended. The choice of operative technique is quite wide – from the removal of bursa, the debridement of the Achilles tendon enthesion to the resection of the osteophytes of the heel hump with the reinsertion of the tendon and prolonged rehabilitation. Conclusions. The causes and pathogenetic mechanisms of pain in the foot are extremely diverse, the patterns of their occurrence and the combination are insufficiently studied. Accordingly, the effectiveness of treatment remains low. Thus, there is a need for further improvement of the ways of diagnosis and supervision of patients with pain in the foot.