Lviv Clinical Bulletin

11-17

Authors: Abrahamovych O., Dudar I., Abrahamovych K.

Introduction. The problem of the quality of life of patients with the chronic kidney disease stage VD treated by hemodialysis is becoming more and more urgent in medicine. One of the most common factors that worsen in patients with chronic kidney disease (CKD) that are treated by hemodialysis – skin itching occurs in 50.0-60.0% of these patients. Itching affects sleep, working capacity, causes depression, sometimes suicidal thoughts. Aim. To increase the efficiency of treatment of patients with CKD and skin itching, which are treated by hemodialysis, with the use of ultraviolet irradiation on the basis of the study of the effect of skin itching on the quality of their life, the state of decomposing cells and proinflammatory cytokines. Materials and methods. The study involved 109 patients with CKD of the VD stage who were undergoing hemodialysis at the Lviv Regional Clinical Hospital and Kyiv City Scientific and Practical Center of Nephrology and Dialysis. The control group was made up of 20 healthy individuals who, according to age and gender, corresponded to the patients of the examined group. There were studied the parameters of the pruritus, the quality of life, the levels of proinflammatory cytokines (IL-1β, IL-17, MCP-1), the presence and activity of the skin mast cells, depending on the presence / absence of the itching skin. Was carried out the ultraviolet radiation treatment and was examined its effect on the itching, the levels of cytokines and the quality of life in 109 hemodialysis patients. Results. In 56.0 % of patients with the chronic kidney disease stage VD was revealed the skin itching which is inversely correlated with the most indicators of the life quality. Proinflammatory cytokines potentially reflect the activity of pruritus in 58.3 % of patients. Was noted a higher number and activity of mast cells in patients with the pruritus compared to patients without it. As a result of the comparisons between proinflammatory cytokines and mast cells was found a direct connection of both in patients with the pruritus. In 100.0 % of patients the ultraviolet radiation treatment helped to eliminate the skin itching. The positive influence of the ultraviolet radiation retained in 45.8 % of patients within one year. The levels of the proinflammatory cytokines in patients with the pruritus decreased in two weeks after the ultraviolet radiation course. Conclusions. It was found that in patients with the CKD stage VD treated by the hemodialysis the itching of the skin significantly impairs the quality of life. It was also found that the ultraviolet radiation treatment reduced the itching of the skin in these patients, resulting in the improvement of the quality of life by 14.8 %.

18-22

Authors: Barnett O., Kyyak Y., Kyyak H., Kovalyshyn V., Besh D.

Introduction. Myocardial hibernation refers to “new ischemic syndromes,” which in recent years have increasingly attracted the attention of cardiologists and cardiac surgeons. Hibernation includes a number of adaptive responses: inhibition of metabolic processes to more complex and lengthy pathophysiological changes that lead to myocardial contractile weakness, and their degeneration of cardiomyocytes and their apoptosis. Aim. To find out the pathophysiological mechanisms of occurrence and ultrastructural signs of cardiomyocyte hibernation in patients with arterial hypertension (AH) and myocardial infarction (MI), as well as the role of hibernation in the occurrence of heart failure (HF). To determine the dependence of segmental disorders of the left ventricular myocardial contractility (hypokinesia, akinesia, dyskinesia) on the presence of hybridized cardiomyocytes and to reveal the duration of their life. Materials and methods. For 36 patients with hypertension and coronary artery disease were examined, were examined the ultrastructure of myocardial biopsy material (n = 10) obtained during coronary artery bypass graft (CABG) and aneurysmectomy, as well as express neoplastic lesions (n​​= 26) in those who died of heart attack. Myocardial biopsies were obtained during the execution of the CABG for angina pectoris (n = 10) or ventriculoplasty in combination with CABG (n = 6). Ultra-structured study of 10 myocardial biopsies during CABG and ventriculoplasty, as well as 26 express-necropsies of the myocardium of those died due to the MI who were ill with hypertension were made. Results. It has been determined that hypertrophy and cardiomyocyte hybridization correlate with the severity of hypertension, MI, besides necrosis, causes stunning, hypertension, apoptosis, and necrosis of cardiomyocytes, mainly in the parainfarction and intact regions of the left venticle. The hepatized cardiomyocytes (irreversibly altered, hybridized cardiomyocytes containing α-glucogens) were first detected. The correlation between the percentage of remodulated cells (from 50.0 to > 75.0%) and the emergence of segmental lesions of the contractility of left ventricle (hypo-, aki-, dyskinesia), which leads to acute and chronic HF was found. Conclusions. Myocardial hibernation is a clinically important syndrome, which is often accompanied, under certain circumstances, by the transient left ventricle dysfunction. It is important to consider it in clinical practice, since hibernation is present in patients with almost all forms of coronary heart disease and requires both medical and surgical treatment.

27-31

Authors: Rudnyk T., Nadashkevіch O., Parashchuk B., Zaychenko Y.

Introduction. It is known that in 15.0-20.0% of the world’s population there is at least one episode of urticaria throughout the life, and therefore it belongs to the group of dermatoses of a social nature. Significant prevalence, absence of unified diagnostic algorithms, multifactorial etiology, often resistance to treatment and rehabilitation measures with a significant decrease in the quality of life of patients is the cause of a careful attention to its study. However, despite the fact that it would be possible to assume the commonality of the pathogenetic mechanisms of allergic dermatitis and damage to the glands of the internal secretion, in particular, thyroid gland, today the insufficient attention is paid to the research of the role of the latter in the occurrence of urticaria, the information about the informativeness of the individual criteria for assessing its condition, the influence of pathological changes of the thyroid gland on the clinical course of urticaria is not outlined. Aim. To investigate the functional state of the thyroid gland in patients with urticaria and to determine its dependence on the severity of the urticaria, its duration, and the long-term duration of the last clinical remission. Materials and methods. 86 patients with chronic idiopathic urticaria (34 men and 52 women) aged 15-67 years were examined. Control group consisted of 20 healthy people. The duration of the disease varied from 5 months to 29 years. The mild course of dermatosis was diagnosed in 31 (36.0%) patients, the moderate – in 24 (28.0%), and the severe course – in 31 (36.0%). The function of the thyroid gland was evaluated by the determining the level of thyroxin, triiodothyronine and tyroglobulin in the blood serum. Results. In patients with urticaria, there is a dependence of the function of the thyroid gland on the presence and duration of the last remission – significant increase of the thyroxine levels and reduction of triiodothyronine level in the blood serum of patients with the continuous course of urticaria and duration of the last remission up to 3 months, and a possible increase of thyroglobulin level in serum in the patients without remission. Conclusions. It was found that urticaria is accompanied by the dysfunction of the thyroid gland which lies in a certain growth of thyroxine and thyroglobulin and in the reduction of triiodothyronine level in the blood serum. The intensity of the changes mentioned above depends on the clinical course of the pathological process, specifically on the presence and progression of the last clinical remission, in this connection it is expedient to further study the involvement of the thyroid gland into the autoimmune processes in patients with dermatosis.

37-45

Authors: Abrahamovych M., Farmaha M.

Introduction. Cirrhosis of the liver is a frequent chronic polyethyologic disease of the internal organs with polymorphous syntropic lesions, which often causes early disability and death of patients – that is why it is necessary to improve the principles of complex differentiated treatment taking into account extrahepatic manifestations of the disease. Aim. To improve the algorithm and to improve the efficiency of treatment of patients with cirrhosis of the liver by taking into account detected extrahepatic co- and polymorbid syntropic lesions of other organs and systems. Materials and methods. The study included 1713 patients with cirrhosis (75.7% of men, 24.3% of women, age 18-86), who performed a comprehensive examination of all organs and systems in accordance with the requirements of modern medicine. Subsequently, patients were divided according to the criteria for classification of C. G. Child – R. N. Pugh by severity at A (38.1%), B (52.3%) and C (9.6%) classes, and a comprehensive differential treatment was performed for 4-6 weeks. The control group consisted of 302 patients, representative of gender, age and severity of liver cirrhosis, which were treated according to the generally accepted method. Results. Among patients with cirrhosis of the liver, 74.3% had varicose veins of the esophagus, 61.3% had gastropathy, 48.2% had varicose hemorrhoidal veins, 19.2% had arterial hypertension, 56.4% arterial hypotension, 57,3% – secondary cardiomyopathy, 27.5% – rhythm disorders, 65,3% – disorders of conduction, 82,9% – signs of hepatopulmonary syndrome, 8,9% – portopulmonal hypertension, 0.8% – signs of hepatolateral syndrome type І, and 3.3% – type II, 56.0% – secondary encephalopathy, 73.1% – signs of the disorders of the autonomic nervous system, 60.5% – osteopenia and 39.5% – osteoporosis, 42.3% – anemia, 29.8% – coagulopathy and 94.2% – signs of skin lesions. In 64.2% of the patients treated using the system we had modified, good results were obtained, in 28.7% the results were satisfactory and 7.1% – were not satisfactory. 73.1% had a good result in patients with class A of liver cirrhosis, 63.9% – class B and 61.8% – class C. The number of patients with satisfactory results was roughly the same in all groups (26.5% -30.4%). In group A, there were no patients with poor treatment outcomes, in group B – 5.7%, and in group C they were 11.7%. The presented actual material allows us to assert that the complex treatment we have modified is effective in 92.9% of the patients with liver cirrhosis. In the significantly lower number of patients treated using the usual method compared to the experimental group (47.4%), good results were obtained, and this was due to a significant increase in the number of patients with only a satisfactory result of treatment (46.7%). In 5.6% of the patients, the results of treatment were not satisfactory, and 0.3% the results were poor. 51.3% of the patients with a good result were patients of class A of liver cirrhosis, 49.4% – class B and 20.7% – class C. The number of patients with satisfactory results, as in the experimental group, was approximately identical in quantity in groups A, B and C (from 46.2% to 48.3%). In group A, 1.7% of the patients had a poor outcome, in group B they were 4.4%, and in group C – 27.6%. Consequently, the generally accepted comprehensive treatment is effective in 94.1% of patients with liver cirrhosis, but for qualitative indices, it is significantly lower than the medical complex we have modified. Conclusions. Modified by the authors, the complex differential treatment of patients with liver cirrhosis, taking into account the presence of polymorbid syntropic lesions, as well as the traditional one gives a positive result, but the effectiveness of conventional treatment is lower compared to the complex we modified.

49-51

Authors: Zinchuk О.

Introduction. Lyme borreliosis (LB) is a polysystemic infectious disease caused by a bacterium Borrelia burgdorferi and transmitted through the suction of ixodic ticks. In the last decade, the incidence of LB in Ukraine has risen steadily; it is officially classified as a group of particularly dangerous infectious diseases. LB often runs syntopetically in the pathologic process of various organs and systems. Heart failure is often found in case of LB, but it is poorly investigated. Aim. To find out the clinical-electrocardiogram signs of heart disease in patients with LB in the western region of Ukraine. Materials and methods. There were 352 patients with LB who were inpatient and outpatient care in the Lviv Regional Infectious Diseases Hospital in 2000-2008. Among the patients, there were 129 men and 223 women. The average age was 45.61 ± 0.81 years. Diagnosis of LB was based on the results of epidemiological, clinical and laboratory and instrumental studies. A clinical case of severe heart failure in a patient with a chronic course of Lyme borreliosis was described. Results. Symptoms of heart function abnormalities were detected in 72 patients (21.6%) out of 333 who were diagnosed with early-onset LB. In 55 of them (16.5%) there were clinical signs of heart disease. Changes in EG were detected in 46 (18.2%) out of 253 surveyed. The most frequent clinical signs that indicated a disorder of the function of the heart were a feeling of discomfort or pain in the area of ​​the heart. Sternal discomfort was seen in18 patients of 333 (5.4%), in 16 (4.8%) – pain in the heart region. 22 patients (6.6%) showed the weakening of the heart tones, 13 (3.9%) – systolic murmur on the apex. An echo study showed that some patients combine several echogenic signs – most often bradycardia with ventricular extrasystoles or conduction disorders of varying degrees. These changes were usually short-lived and disappeared after the treatment with antibiotics. Antimicrobial treatment in common doses (Uniodox – 4 patients, Ceftriaxone – 3 patients, Amoxicillin – 1 patient) contributed to the gradual normalization of the condition of the patients. Clinical and ECG-changes in patients with myocarditis normalized within 3-4 weeks – in 6 out of 8. In 2 patients after discharge from the clinic, the relaxation of cardiac tones, ventricular repolarization disorders in the form of tinnitus reduction, which required the additional treatment, was maintained. Despite the benign course of myocarditis in most patients with LB, the lack of early specific antimicrobial treatment due to the inadequate diagnosis can be a reason for the progression of the pathologic process in heart tissue with severe consequences. Conclusions. It was found that the clinical symptoms of heart disorders were present in 16.5 % of patients in early period of Lyme borreliosis and electrocardiographic changes – in 18.2 %. These symptoms were present more often in the group of the patients without erythema migrans. There were 2.4 % of patients in early period of the disease with the symptoms of myocarditis. These patients need a permanent detailed monitoring of the cardiac activity during all periods of the disease for the prescription of an adequate treatment.

56-60

Authors: Smoljar N., Bezvushko E.

Introduction. The problem of dental caries is one of the most urgent because of its significant prevalence and intensity in many countries all around the world. At the same time, the information statistics of the WHO shows a decrease in the rate of dental caries in most developed countries, as well as the stabilization of the incidence or the slowdown of its growth in some developing countries. Studying the frequency of dental diseases with the analysis of their causes is the basis of primary prevention. An epidemiologic examination of children is considered essential in assessing the dental morbidity and conducting the optimal preventive measures, taking into account information about their residence in specific natural and social conditions. The analysis of literature is showing a significant variability in the spread of dental caries not only in different regions of Ukraine, but also among the children living within the same city. Aim. To estimate the prevalence and intensity of caries of teeth in children of Lviv and Lviv region and to find out their dependence on the age of the surveyed. Materials and methods. 2387 children were surveyed in 20 towns of Lviv region and 454 children in Lviv. The survey was conducted in key groups of 7, 12, 15 years in accordance with WHO guidelines for epidemiological studies. The defeat of teeth by caries was estimated by the following indices: prevalence of caries of teeth (%), caries intensity by index CSR (C – caries, S – sealed, R – removed tooth). Results. It was determined that the average prevalence of caries is 81.44 % with 3.68 harmed teeth. The affection of teeth by caries is growing with age. The prevalence of caries in 7-years- old children is a 63.56 %, with the intensity of 1.20 harmed teeth. In 12- years-old children, accordingly – 91.60 % and 3.84 teeth and in 15-years-old children – 90.66 % and 6.09 teeth per one child. The considerable differences in the indexes of teeth affection by caries were established depending on the territory of residence of the children, as well as the age – a considerable increase of the intensity of teeth caries was observed in 12- to 15- years-old children. The analysis of the results of the examination of children made it possible to reveal a different level of prevalence and intensity of dental caries, as well as an insufficient level of providing the metamorphosed dental care. This testifies to the need for further examination of children in other populated areas, the study of the nature and impact of the ecological, natural, geochemical and other factors of the environment in which the children live, not only on the development and formation of solid dental tissues, but also on the state of their dental health. Conclusions. The prevalence and intensity of caries of teeth in children of the Lviv region according to the criteria of the wound are high. It is necessary to develop the preventive measures for the preservation of the health of children, as well as efficiently organize dental care for children.