Lviv Clinical Bulletin

15-19

Authors: Vares Ya., Chegrynec N.

Introduction. Intermaxillary fixation is an important and inseparable constituent part of treatment of trauma patients which provides an adequate interocclusal relationship. It can be employed as a solely conservative moda lity for fracture treatment as well as obligatory assistance of jaw osteosynthesis in case of its traumatic injury. The essential drawbacks of the existing methods of intermaxillary fixation, particularly dental arch bars and ligatures, are negative infl uence on periodontium, complicated hygiene, non-balanced muscular loading, pain and psychological discomfort to the patient etc, which requires a search for alternative methods. A stream development and inculcation to the clinical practice of various orthodontic systems in recent decades allow extrapolating the indications for their employment from orthodontics to other dental directions, especially maxillofacial traumatology. The purpose of the study is a retrospective analysis with clarification of historical aspects and generalization of own experience of employment of non-removable orthodontic technique (bracket system) for fixation of bone fragments in cases of traumatic mandibular fractures. Materials and research methods. Since 2012 in the Department of Surgical Dentistry and Maxillofacial Surgery of The Danylo Galytsky LNMU 57 patients (men – 45, women – 12; age 18 – 45) with traumatic mandibular fractures were examined and treated surgically (control group, 35 patients) and conservatively (main group, 22 patients). In all patients of the main group the intermaxillary fixation was carried out using the elements of non-removable orthodontic technique – brackets VictoryÒ with hooks (specification 0° TQ, 0° ANG, 022) (3М Unitek, USA), which were fixed on teeth according to standard protocol, including acid enamel etching, employment of adhesive, fixation of brackets with light-curing composite). Later the hooks of opposite brackets were joined together by elastic rubber rings in proper occlusal relationship. Control inspection of patients was carried out on 1, 3, 7, 14, 21, 30, 60 and 90 days post-operatively. Results. The obtained results of employment of non-removable orthodontic elements (brackets) for bone fragments fixation in 22 patients with traumatic mandibular fractures were evaluated by us as satisfactory. The mean period of intermaxillary fixation was 19 ± 2 days. On that time clinical and roentgenological signs of fracture consolidation were observed in all patients and there were no occlusal disturbances in any case as well as other complications except of unglue of brackets from the teeth surface. There were no patients’ complaints regarding laboured oral hygiene and service of orthodontic appliance. Positive results of investigation are confirmed by the demonstration and description of a clinical case. Conclusions. Summarizing the results of a brief retrospective literary analysis as well as our own clinical experience it could be asserted that employment of elements of non-removable orthodontic technique (bracket system) for fixation of bone fragments in cases of traumatic mandibular fractures creates a serious alternative to the existing methods of an intermaxillary fixation. The proposed method allows to reestablish an adequate anatomical and functional status of the mandible in short terms, facilitates oral hygienic maintenance, requires no local anaesthesia and is suitable for both balanced occlusal loading distribution and, oppositely, correction of occlusal relationship by means of directed elastic pull.

27-35

Authors: Fedevych S.

Introduction. Implementing into medical practice target therapy in cancer patients including the conventional (clear cell) renal cell carcinoma (CCRCC) provides the delivery of anti-angiogenic and conventional cytoreductive agents through “normalized” ways of the vascular network of tumors to cancer cells. We also know that microcirculatory bed and its microenvironment in tumors are formed by vasculogenesis and angiogenesis, unlike normal tissues, are characterized by the presence of primitive vessels and abnormal microenvironment. However, no stu dies were conducted, which would have characterized in comparative plan the ultrastructural organization of tumor microvessels in CCRCC of different grades of differentiation. The aim is to examine ultrastructural organization of microcirculatory bed in conventional (clear cell) renal cell carcinoma of different grades of differentiation. Materials and methods. Material for conducting transmission electron microscopic researches was postoperative biopsies of peripheral and central parts of tumors in CCRCC at high differentiated cancer (G 1) – three cases: one man (61-years-old) and two women (49- and 61-years-old); with an average grade of differentiation (G 2) – three cases: two men (43- and 66-years-old) and one woman (69-years-old); with a low grade of differentiation (G 3) – six cases, all were men (48-, 52-, 56-, 70-, 71-, 75-year-old). Material for conducting of сontrol studies in transmission electron microscopy was postoperative biopsies of renal cortex of eliminated parts of the kidney with tumor and the whole kidney with tumor in these patients with CCRCC. The technique is common in transmission electron microscopy. Results and discussion. At the ultrastructural level, vascular buds, primordial endothelial cells, optimally developed capillaries, forming capillaries, already formed capillaries, small venules, primitive capillaries, hematopoietic cells, mesenchymal cells, fi bers of collagen studied in peripheral stroma of tumors with high differentiated (G 1) CCRCC. In the central part of the tumors there are small numbers of cells that are in the process of apoptosis, decomposition and necrosis. Gaps of disorganized capillaries are rich in accumulations of erythrocytes, platelets and fi brin monomer bundles of fi bers, gaps of small venules with wrinkled walls are rich in a homogenous blood plasma. The sclerotized stroma of tumors with an average grade of differentiation (G 2) CCRCC contains mesenchymal cells, disorganized bands of primordial endothelial cells, hypertrophic capillaries and small venules. The luminal surfaces of endothelial cells of the vessels are formed by a large number of microvilli. Their gaps contain hyperaggregates of erythrocytes, polymorphonuclear granulocytes, monocytes, platelets with high electron density, fibrin polymer bundles of fi bers, the large drops of lipoprotein. At the low grade of differentiation (G 3) CCRCC, the considerable areas of epithelium- and endothelium-containing formations of peripheral and more central parts of the tumor are disorganized, and are in a state of apoptosis and necrosis. It was observed that the modified tumor apoptotic epithelial cells with surrounding fibrin polymer bundles of fibers and adjacent the remodulated stroma were rich in mononuclear cells, monocytes, hematopoietic cells, mesenchymal cells, primordial endothelial cells, vascular buds, capillaries of sinusoidal type, primitive capillaries, newly formed capillaries and small venules. The control studies made it possible to establish that the ultrastructural organization of optimally developed capillaries of peripheral part of tumors with high differentiated grade CCRCC is close to that of peritubular capillaries of renal cortex of patients with high differentiated (G 1) CCRCC and kidney of mammals. Conclusions. The ultrastructure of microcirculatory bed of tumors with a high grade of differentiation (G 1) is a more “normalized” than the average one (G 2) and the low (G 3) grade of differentiation CCRCC.

42-54

Authors: Ferko M.

Intraduction. Liver cirrhosis is one of the most difficult diseases in the world to the diagnosis and treatment of which special attention is paid. The prevalence of liver cirrhosis and mortality caused by it is very different across countries and tends to increase. The incidence of liver cirrhosis increased over the past 10 years in developed countries in 10.0-15.0 %. Information on mortality due to the liver cirrhosis is ambiguous – from 8 to 80 per 100 thousand population. It was learned that liver cirrhosis is not limited by the injury of hepatobiliary system, but also extends to other organs and systems that can be considered as cirrhotic disease of the whole organism with involvement into the pathological process of various organs and systems of the human body, interpreted as syntropic comorbid lesions, which in most of the cases cause temporary, and in the future – sustainable abnormal function, disability, often – death of the patient. Today it is premature to assume that the problem of treatment of the cirrhotic patients is solved due to the fragmentary information, obtained using a variety of different models in experimental and clinical conditions, ignoring the severity of portal hypertension and syntropic comorbid extrahepatic lesions and their complications, does not allow to affect substantially on the treatment effectiveness of these patients, improve their quality of life. This determines the relevance, medical, social and economic significance, and also the need for the improvement of the principles and increase the efficiency of complex differential treatment of the cirrhotic patients considering the severity degree of portal hypertension and comorbid syntropic extrahepatic lesions and their complications that are still not performed. The aim of our study was to improve the algorithm and increase the treatment effectiveness of patients with liver cirrhosis taking into account the severity degree of portal hypertension and comorbid syntropic extrahepatic lesions and their complications. Materials and methods. After obtaining written consent in accordance with the principles of the Helsinki Declaration of Human Rights, the European Convention on Human Rights and Biomedicine and Legislation of Ukraine into the study in randomized manner with the preliminary stratification by the presence of liver cirrhosis were involved 240 patients who were hospitalized with the aim of the examination and treatment into created on the basis of the Internal Medicine Department N 1 of Lviv National Medical University and Gastroenterological Department of Lviv Regional Clinical Hospital, Lviv Regional Hepatological Center. According to the results of an ultrasound dopplerfloumetric examination of the abdominal cavity vessels, all the patients were stratified into three groups: the first – patients with I degree portal hypertension – 122 persons [33 women (27.0 %) and 89 men (73.0 %), aged 21 to 78 years (average age 46,4 ± 1,0 years), including 78 patients (57.4 %), for whicha comprehensive differentiated treatment with the help of modified by us algorithm was conducted (experimental group) and 44 patients (42.3 %), for which there was conducted a comprehensive treatment due to the conventional method (Order of the MPH of Ukraine from 13.06.2005, N 271 – the control group), the second patients with II degree portal hypertension – 57 patients [14 women (24.6 %) and 43 men (75.4 %) aged 27 to 66 years (average age 48,2 ± 1,3 years), including 26 persons (19.1 %) – experimental group and 31 patients (29.8 %) – control group], the third group – patients with III degree portal hypertension – 61 patients [18 women (29.5 %) and 43 men (70.5 %) aged 29 to 73 years (average age 50,2 ± 1,3 years), including 32 patients (23.5 %) – experimental group and 29 patients (27.9 %) – the control group]. The criteria for evaluating the treatment results were as follows: excellent result – recovery; good result – a significant improvement, most values of the indices returned to normal; satisfactory result – a slight improvement, some values of indices have improved; bad result – no improvement and a very bad result – deterioration or transformation into cancer. For the direct assessment of the life quality of the patients with cirrhosis, we used a questionnaire MOS 36-Item Short-Form Healh Survey, created by J. E. Ware in 1992. Results and discussion. In accordance with the aim, we have developed a comprehensive differentiated pathogenetically grounded individualized landmark treatment algorithm for the patients with liver cirrhosis taking into account the severity degree of portal hypertension, syntropic comorbid extrahepatic lesions and their complications. It was found that it is effective in 93.6% of the patients, as well as in 9.5 % (p < 0.05) for the value exceeds the conventional method (Order of the MPH of Ukraine from 13.06.2005, N 271). According to the results of our study, we can say that the improved algorithm for the treatment of patients with liver cirrhosis and a common methodology gives a positive result, but in terms of qualitative and quantitative indices, generally accepted medical complex is significantly inferior to modified by us algorithm. Conclusions. Treatment of the patients with liver cirrhosis according to the modified by us algorithm is effective for the results of evaluation of physical parameters and quality of life. It must be comprehensive, that, except of the impact on the etiological factor, its main pathogenetic links, commits to take into account the severity of portal hypertension and the presence of syntropic comorbid extrahepatic lesions and their complications.

59-64

Authors: Lopina N.

The purpose of research is to evaluate the association of fractalkine level with non-modifiable and modifiable factors of cardiovascular risk, and the severity of the atherosclerotic lesions of the coronary arteries. Materials and Methods. 131 patients with coronary artery disease (CAD) were examined. Depending on the presence of type 2 diabetes mellitus (T2DM), patients with CAD were divided into 2 groups: 1st group (n = 70) – patients with concomitant T2DM, 2nd group (n = 61) – patients with CAD without T2DM. All patients were performed coronary angiography to verify the diagnosis of CAD. Also in all patients were evaluated anthropometric indicators, the levels of fractalkine, indexes of lipid and carbohydrate metabolism. Results. The study found that patients with CAD both with concomitant T2DM and without had increased levels of fractalkine signifi cantly compared with the control group. In patients with hemodynamically significant stenosis, diffuse coronary lesions with concomitant T2DM and without had significantly higher fractalkine levels. In assessing the relationship fractalkine with non-modifiable risk factors there were established the presence of a weak correlation with age, unreliable weak correlation with experience of T2DM, no statistically significant average correlation with experience of CAD. In assessing the relationship fractalkine with anthropometric indices there were established the presence of a weak correlation with weight, the volume of the thighs, the ratio of waist size and hip and average positive correlation with a volume of waist, which confi rms the fact that the abdominal obesity increases the synthesis of fractalkine adipocytes. In assessing the relationship fractalkine with lipid metabolism, it was found the presence of a weak correlation with total cholesterol, triglycerides, VLDL, the level of LDL cholesterol. In assessing fractalkine relationships with indicators of carbohydrate metabolism, has been established the presence of a weak correlation with the index of a short-term glycemic control – glucose and secondary with an indicator of a long-term glucose control – HbA1c. The analysis of correlations between the level of fractalkine and severity of CAD has been established the existence of significant correlations: strong – between the amount of atherosclerotic plaques of coronary vessels, the middle – between the number of affected vessels, the number of diseased coronary artery segments, weak – the number of lesions of the proximal middle and distal segments, the number of hemodynamically significant stenosis of the coronary arteries. Conclusions. Results of the study demonstrate the impact on the level of fractalkine age, duration of CAD, metabolic status and indicators of glycemic control, abdominal obesity. Increasing fractalkine level is associated with more severe atherosclerotic process. The study shows the impact on the development and progression of atherosclerosis, endothelial dysfunction, especially in patients with concomitant T2DM and abdominal obesity.

14-22

Authors: Abrahamovych O., Abrahamovych U., Kushyna A., Guta S., Synenkyi O.

Introduction. It is known that the course of systemic lupus erythematosus (SLE) is often accompanied by the syntropic lesions of the cardiovascular system, among which hypertension has a significant role. Being an important risk factor for the emergence and growth of the severity of syntropic cardiovascular complications in patients with SLE, especially in its active phase, hypertension often impairs their quality of life, and at times is the main cause of death. The purpose of the study is to discover the dependence of the parameters of daily blood pressure monitoring (DMAT) on the pathological process activity in patients with SLE. In order to achieve this objective our goals were to evaluate the following DMAT parameters in SLE patients depending on the pathological process activity: 1) blood pressure in SLE patients during the period of 24 hours; 2) blood pressure in SLE patients during the active and passive periods. Materials and research methods. In a rheumatology centre of Danylo Halytsky Lviv National Medical University at Lviv regional clinical hospital in a randomized manner were examined 83 patients (71 women and 12 men aged 17­68) diagnosed with SLE, who afterwards were stratified into three groups according to the pathological process at the time of DMAT: with the activity of degree I (25 women and 5 men, average age 42,9 ± 2,1 years, with the activity of degree II (33 women and 6 men, the average age 37.9 ± 1,8 years), with the activity of degree III (13 women and 1 men, average age 37.9 ± 1,8 years). The control group consisted of 35 practically healthy individuals of the same sex and age. DMAT was performed with the use of the apparatus ABPM-04 (company “Meditech”, Hungary), the monitor was being activated every 15 minutes during the daytime (from 6 a.m. till 9:59 p.m.) and every 30 minutes during the nighttime (from 10 p.m. till 5:59 a.m.). According to the first goal was rated the BP in the SLE patients during the period of 24 hours, for which: a) were examined the average daily, maximum and minimum levels of systolic blood pressure (SBP), diastolic blood pressure (DBP), the average blood pressure; b) was analysed the daily index (DI) of SBP, DBP and the average blood pressure; c) was examined the time index (TI) of SBP, DBP and the average blood pressure. According to the second goal was rated the blood pressure in SLE patients during the active and passive periods, for which: a) were examined the average daily, maximum and minimum levels of SBP, DBP, the average blood pressure during the active period; b) were examined the average daily, maximum and minimum levels of SBP, DBP, the average blood pressure during the passive period; c) was studied the TI of SBP, DBP and the average blood pressure during the active and passive periods. Were compared the DMAT indices in patients with different degrees of activity of SLE: patients with the SLE activity of degree I were compared with the patients with the SLE activity of degree II and III, patients with the SLE activity of degree II were compared with the patients with the SLE activity of degree III. The actual material was processed on a PC with the help of Microsoft Excel using descriptive statistics and Student’s t-test in order to compare the samples with a normal distribution. For all the examined patients were applied the principles of the Helsinki Declaration of Human Rights, the European Convention on Human Rights and Biomedicine. Results of the investigation and their discussion. After the indices of blood pressure in patients with SLE were compared during the day in general, was stated the availability of the increase of blood pressure with the increase of the degree of the SLE activity on almost all indicators (except the maximum DBP). This pattern of the consistent growth, depending on the severity of the disease, was proved by the results of average estimation of daily SBP, minimum SBP, average daily DBP, minimum DBP, daily and minimum average blood pressure. Of all the indicators which are characterized by the increase of blood pressure in patients with the SLE with the activity of degree II compared with patients with the SLE with the activity of degree III, the indices of average SBP are accurate. The most convincing information, that truly confirms the increase of blood pressure with the increase of the SLE activity, was detected in patients of the third group comparing seven out of nine (except the maximum DBP and SBP, the results of which are unreliable) indicators of SBP, DBP and the average blood pressure with the patients of the second (except the maximum SBP, the level of which varies, but not significantly) and the first groups. Since DI is a significant indicator that shows a violation of the circadian rhythm of blood pressure due to its insufficient decline during the night period, the obtained results can be interpreted as a sign that an increase in the activity of SLE increases the severity of a violation of circadian rhythm changes in blood pressure with a decrease in the number of patients with preserved physiological rhythm, increase of the deficit of blood pressure reduction during a passive period and the increase in the number of the so-called “night-peakers” patients with the phenomenon of “non-dipper”, which may indicate a malignant course of hypertension, the presence of its symptomatic form and is considered to be an independent risk factor of cardiovascular complications. The obtained results of TI studies show, that with the increase of the SLE severity the frequency of episodes in which the blood pressure exceeded the permissible limits, was increasing. All the nine indicators, that characterize the blood pressure during the active period, investigated in patients with I, II and III levels of activity, increased naturally (except the maximum DBP in the third group) with the increase of the degree of SLE activity, and the most directly-proportional dependence of the increase of the severity of disease and the value of the investigated parameters is observed in the III group patients compared with the II and especially the I group patients. All the nine indicators, that characterize the blood pressure during the passive period, investigated in patients with I, II and III levels of activity, increased naturally with the increase of the degree of SLE activity, and the most directly-proportional dependence of the increase of the severity of disease and the value of the investigated parameters is observed in the III group patients compared with the II and especially the I group patients. Out of the six parameters of TI in patients of the three groups only the SBP TI was below the reference parameters in patients of the first group with the SLE activity of degree I during the active period and all three indices in patients within this group (SBP, DBP and the average blood pressure) are higher during the passive period than during the active. All the six indicators characterizing the TI during both active and passive periods naturally increase with increase of the degree of activity of SLE, and most clearly a directly-proportional dependence between the increase of the severity of disease and the value of the investigated parameters is observed in the III group patients compared with the II and especially the I group patients. Conclusions. In patients with SLE the indices of DMAT depend on the activity of the pathological process – the blood pressure increases significantly with its rise on almost all parameters (except the maximum DBP), with the change of the physiological circadian rhythm due to its insufficient decline in the night period and with an increase of frequency of episodes in which the blood pressure exceeds the permissible limits. The identified patterns of changes of DMAT are also preserved throughout the period of 24 hours, and according to the results of their separate evaluation during a nighttime and daytime so that during a passive periods these figures are significantly more often lower than the reference values, especially in patients of first and second groups.

28-29

Authors: Aladashvili L., Arabuli M., Tchlikadze N.

Іntroduction. The diameter and deformability of red blood cells (RBCs) play a very important role in the maintenance of normal blood flow in the microcirculation. RBCs deformability has been described based on three physical properties: membrane viscoelastic properties, the internal viscosity and the surface area-to-volume ratio. The membrane properties and thus the deformability of RBCs are largely detailed and considerable information is available regarding the skeleton composition, ultrastructures, protein- to-protein interactions, membrane anchorage, and molecular defects. The aim of the research was to study the age-related changes of diameter and deformability of RBCs in practically healthy volunteers. Materials and methods. Morphological and biophysical parameters (diameter, deformability) of RBCs were studied in 50 practically healthy men – volunteers. They were divided into two age groups: adults (22-30 years old, 25), and old people (75-89 years old, 25). For a morphological research were made smears, which were dyed by Sudan Black according to the method of F. A. McManus. Diameter of erythrocytes was measured with the ocular micrometer. The deformability of erythrocytes was determined with the help of the computer filter-photometer method. The time of the diffusion on the filter paper was determined for this pattern. Statistic processing of obtained results was conducted according to the program SPSS, version 11.0. Student’s t-test was used for analysis of differences between means and a change with a p < 0.05 was considered statistically significant. Results. RBC ageing is closely related to a progressive decrease in ADP/ATP ratio, which provides disorders of osmotic balance, cells’ swelling, activating signal transduction system, which affects properties regulating RBC deformability and finally leads to the removal of old cells from the circulation by macrophages at spleen level. It was shown that the number of the RBCs that passed the filter paper per time unit in old people is statistically significantly low compared to the young people. So there is a tendency of the increase of the diameter of RBCs in aged people, this indicates that the volume of erythrocytes is increased in old people. Conclusions. The excessive number of large-sized matured (aged) erythrocytes is revealed in the blood of old people. Different rheological characteristics of RBCs in various aged volunteers have as a result the aged-related cardiovascular diseases.

41-50

Authors: Tolopko S. Ya.

Introduction. Today we know, that the course of liver cirrhosis (LC) depends on a number of factors: the nervous and humoral regulation, the proportion of cells, that form the sinusoidal blood flow, neurotransmitters of the autonomic nervous system and other features, that ensure the normal course of the physiological processes and portal pressure maintenance. The result of their equilibrium disorder is the formation of collateral blood flow, esophageal varices, often associated with portal gastro- gantry, entero-, colopathy, splenomegaly, ascites. Changes ofthe blood circulation, accompanying LC, is the basis not only for portal hypertension and its characteristic complications, but also for blood flow disorders, practically, in all organs, including the lungs, with the appearance of the severe pathological changes there, which have, in this case, the causal connection with the degree of pressure increase in the liver portal system. Assessment of the respiratory system status in cirrhotic patients and the dependence of the syntropic disorders on the severity of the disease would optimize the assistance for this large group of patients, but until now this aspect of the problem has not been studied. Purpose of the study. To describe the status of the respiratory system in patients with liver cirrhosis and the dependence of its syntropic lesions on the severity of the disease due to C. G. Child – R. N. Pugh class. Materials and research methods. In a randomized way with preliminary stratification by the presence of respiratory dysfunction, caused by birth defects, hereditary diseases of respiratory system, infectious, autoimmune, allergic, neoplastic, toxic and occupational factors, identified as syntropic, we have involved into the study 93 cirrhotic patients (45.4 % of all surveyed persons [29 women (31.2 %) and 64 men (68.8 %) aged 27 to 73 years, the most able-bodied population category]) and divided them by the severity classes of LC (criteria of C. G. Child – R. N. Pugh). To achieve the aim of the study all the patients were examined using clinical-laboratory and instrumental methods. Was conducted a clinical review, was determined the arterial blood oxygen saturation in standing and lying position, using pulse oxymetry, were calculated some indices of cardiovascular functioning (heart rate, pulse blood pressure, medium dynamic pressure, peripheral resistance, minute volume of blood), the study of blood gas composition of the venous blood and alveolar-arterial gradient for oxygen, spirometry (determination of lung capacity, respiratory volume, minute volume of breath, forced vital capacity, forced expiratory volume in 1 minute, Tiffno index), electrocardiography and echocardiography, was calculated the average pressure in the pulmonary artery, followed by statistical processing of the results. According to the results of our study can be observed the tendency of negative dynamics of respiratory failure in cirrhotic patients, depending on the severity of the disease by the criteria of C. G. Child – R. N. Pugh. All the patients of the experimental group showed the signs of increasing dyspnea with acrocyanosis and the appearance of “spider veins”, symptoms of hypoxemia, more expressed in a lying position, increased minute volume of blood, that deepens it, because of the reduced transit time of blood, and, respectively, the gas exchange through the expanded lung capillaries. Intense reduction of the partial pressure of CO2 indices, O2 partial pressure, blood oxygen saturation, total CO2 level, free and bound O2 levels, compared with the reference rates (p < 0.05), confirm the presence of hypoxemia, due to disorders of ventilation-perfusion relationships and formation of arterio-venous shunts. Conducted instrumental examination revealed the nature of the restrictive type of dyspnea and deny the signs of pulmonary hypertension in these patients. Conclusions. Among the diseases of the respiratory system 54.6 % of cirrhotic patients had concomitant lesions. The incidence of diffuse pneumofibrosis syndrome was 45.4 % and was significantly (p < 0.05) raising with the increase of the disease severity according to C. G. Child – R. N. Pugh and therefore, has common cause and/or pathogenic mechanisms with it, which makes it a syntropic hepato-pulmonary syndrome. In patients with liver cirrhosis and syntropic hepato-pulmonary syndrome the indices of oxygen saturation of capillary and venous blood and its gas composition were significantly lower (p < 0.05) compared with the reference rates, and its severity, assessed by the results of clinical-laboratory and instrumental survey of respiratory system, has directly proportional dependence on the class of liver cirrhosis by C. G. Child – R. N. Pugh – the heavier liver damage, the more severe dyspnea, lung ventilation function violations of restrictive type with hypoxemia and blood gas composition disorders, with reduced ability of hemoglobin to bind and also carry oxygen and more pronounced formation of arterio-venous shunts.

55-62

Authors: Kyyak H.

Introduction. According to various international registries, the proportion of patients with type 2 diabetes mellitus in a cohort of patients with acute coronary syndrome ranges from 22.0 to 34.0 %. The onset of acute coronary syndrome in those patients occurs, on average, 14.6 years sooner than in patients without diabetes. Diabetes mellitus in patients within first 30 days after myocardial infarction and within next 1–5 years is associated with a higher hospital and general mortality. Aim. To find out the clinical and functional peculiarities of the acute coronary syndrome and concomitant type 2 diabetes mellitus. Materials and methods. 102 patients (49 men and 53 women, aged 54 – 75 years) were examined. Depending on the clinical variant of acute coronary syndrome and the presence or absence of concomitant diabetes, patients were stratified into the following groups: the first group included 60 patients with unstable angina and with non-ST myocardial infarction, including 33 patients with diabetes and 27 patients without diabetes; the second group included 42 patients with ST myocardial infarction, which included 24 patients with diabetes and 18 patients with- out diabetes. Results and discussion. In patients with acute coronary syndrome and concomitant type 2 diabetes mellitus was recorded a late hospitalization in specialized departments, increased heart rate and a greater number of episodes of sinus tachycardia, higher levels of systolic and diastolic blood pressure, the greater size of the left atrium, increasing blood glucose levels and also atherogenic dyslipidemia. For patients with unstable angina and non-ST myocardial infarction the presence of concomitant type 2 diabetes, characterized by lower indices of left ventricular ejection fraction and slightly higher prevalence of symptoms of acute heart failure were observed. In patients with ST myocardial infarction and diabetes increased interventricular septum thickness, posterior wall of the left ventricle, prolongation of QT interval and a slightly higher tendency of patients to ventricular tachycardia and ventricular fibrillation compared with patients without diabetes were observed. Conclusions. Patients with the acute coronary syndrome and concomitant type 2 diabetes were characterized by late hospitalization in specialized departments, apparently due to the presence of atypical and silent disease that requires diagnostic coronarography for further diagnosis. The flow of acute coronary syndrome in these patients was characterized by a higher heart rate, higher blood pressure, prolongation of QT interval, frequent arrhythmias and signs of acute heart failure and subsequently with poorer prognosis.

17-21

Authors: Vares Y., Kyyak S.

Introduction. Management of the asymptomatic and without any pathological changes impacted mandibular third molars should be based on a detailed assessment of all advantages and risks. It is very important to make a correct diagnosis based on the clinical and radiologic data and to prognose the eruption or pathological changes appearance. While the number of asymptomatic and without any pathological changes impacted mandibular third molars is approximately 80.0 %, the question of prophylactic removal is actual. Simultaneously, a considerable prevalence of mandibular third molar impaction in the clinical practice of dental surgeon causes careless attitude to the stage of atypical removal planning. This provokes unpredictable prolongation of operative time, postoperative period, intra- and postoperative complications, which arise in 30.0–40.0 % of the cases. The aim of our study was to create an algorithm for determining of the treatment strategy for patients with asymptomatic and without any pathological changes impacted mandibular third molars and create scheme of their atypical removal in accordance to the clinical case. Material and research methods. With the aim of correct management of asymptomatic and without any pathological changes impacted mandibular third molars a number of criterion were collected and classified. In order to perform a correct planning, prediction of atypical removal and analysis of potential postoperative complications we created a computer program ″Xray analyzer″. Results of the investigation and their discussion. 21 criteria written in the table (table 1) give us a possibility to find out a proper treatment tactic, namely removal of lower third molar. For planning the operation we used the computer program ″Хray analyzer″ which helped us to shorten the time of operation and avoid the intra- and postoperative complications. Conclusion. Created algorithm of clinical and radiologic examination of the patients helps in indicated clinical case to set indications for correct management of asymptomatic and without any pathological changes impacted mandibular third molar. Detailed diagnostic and operation planning with the help of computer program considerably simplify operation process and reduce the intra- and postoperative complications.

26-30

Authors: Synenkyi O.

Introduction. Vitamin D has multiple physiological functions in the human organism and is associated with the pathogenesis of several autoimmune diseases including rheumatoid arthritis. The aim of the study was to evaluate the the level of 25(OH)D in the serum of patients with polyarticular form of rheumatoid arthritis and its dependence on certain clinically significant parameters. Materials and research methods. The study included 93 patients with rheumatoid arthritis, 74.2 % were women. Mean age of women was 53.45 ± 11.16 and of men – 53.29 ±12.06 yrs old. Mean duration of the disease was 8.59 ± 5.99 yrs. Subjects suffering from liver and kidney insufficiency and those who had received vitamin D in the previous 3 months have been excluded. Disease activity was assessed by DAS-28, joint pain degree, morning stiffness time and laboratory measures including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP). 25(OH)D level was evaluated by electrochemiluminescence method. The level of 25(OH)D in serum was evaluated depending on some clinically important parameters: duration of rheumatoid arthritis, clinical signs of the disease, presence or absence of rheumatoid factor in serum (seropositive/seronegative rheumatoid arthritis), some other laboratory parameters of the activity of the process [ESR, CRP, antibodies to cyclic citrullinated peptide (A-CCP)], the degree of activity, functional failure of the joints, Rtg-stage, presence or absence of complications, the dose of methylprednisolone, methotrexate, which were received by patients. Results of the investigation and their discussion. In patients with rheumatoid arthritis the frequency of vitamin D decrease was 92.4 %. The level of 25(OH)D was significantly associated with DAS-28 (r = -0.36, p = 0.001), including the amount of the injured joints (r = -0.36, p < 0.001), ESR level (r = -0.26, p < 0.05), CRP level (r = -0.24, p < 0.05). The mean level of 25(OH)D in serum is significantly lower in patients with rheumatoid arthritis of maximum degree activity, compared with those in whom the disease has minimal activity (16.6 ± 9.3 vs 22.6 ± 9.7 ng/ml). The risk of high disease activity is in patients with vitamin D level less than 20.0 ng/ml: RR = 3.00 (95.0 % CI; 1.01-8.86, p < 0.05). Conclusions. In patients with rheumatoid arthritis the level of vitamin D was decreased in majority of the patients. The level of 25(OH)D was significantly associated with DAS-28, including the amount of the injured joints, ESR, CRP level. The mean level of 25(OH)D in serum was significantly lower in patients with rheumatoid arthritis of maximum degree activity, compared with those in whom the disease has minimal activity. The risk of high disease activity was greater in patients with vitamin D level less than 20,0 ng/ml. Vitamin D deficiency can be an important factor in worsening of rheumatoid arthritis. Vitamin D supplementation is needed to be recommended for treatment of the patients with rheumatoid arthritis routinely.

40-42

Authors: Shymon M.

Introduction. In economically developed countries, diabetes is ranked fourth in the ranking of the most common causes of death. It is known that 75.0 % of complications of diabetes mellitus (DH) due to cardiovascular or kidney damage are due to arterial hypertension (AH), which is twice as likely to occur in patients with DM than in other groups of patients. For a combination of DMwith hypertension, the risk of coronary heart disease increases by 2-4 times, stroke – twice or triple. Thus, hypertension in patients with diabetes should be as early as possible to diagnose and start treatment as soon as possible. Aim. To analyze the results of international studies and current recommendations regarding the target level of systolic and diastolic blood pressure (BP) in patients with DM. Materials and methods. Content analysis, method of system and comparative analysis, bibliosemantic method was used to analyze the data of the international studies (UKPDS, HOT, ADVANCE, ACCORD and ONTARGET) and modern recommendations of ESC, AHA, ACC and CDC, as well as the recommendations of the Ukrainian association of cardiologists, for the target levels of systolic and diastolic blood pressure. Results. In the 60’s and 90’s of the last century deepening the knowledge about the harmful effects of high BP on the organs led to a change in the guidelines of the treatment of hypertension. There was a change in the targets of BP as a goal of treatment. If in the 60’s the desired result of treatment was considered to reduce BP to 160/90 mm Hg, in the 90’s it was to keep the BP in the range of 140/90 mm Hg. According to these recommendations, lowering the BP levels is important in preventing the macular and microvascular complications of DM. In most of the recommendations suggested in the following years, there are no specific indications for the target levels of blood pressure and these comments have not been made in the key algorithm of the treatment for adults with AH. The guidance and unified clinical protocol “Arterial Hypertension”, developed by the working group of the Ministry of Health of Ukraine on the basis of the recommendations of the Association of Cardiologists of Ukraine and approved by the Order of the Ministry of Health of Ukraine N 384 dated 24 May 2012, include such requirements for the treatment of hypertension in patients with DM type 2: patients with diabetes should be treated to achieve the systolic BP ≤130.0 mm Hg (class C) and diastolic blood pressure <80.0 mm Hg (class A). The indicated target BP levels are the same as the threshold level of BP at the beginning of the treatment. Combined treatment using two first line drugs may be considered as an initial treatment in cases of hypertension, if systolic blood pressure is 20.0 mm Hg or if diastolic blood pressure is 10.0 mm Hg higher than the target (class B). Conclusions. It can be concluded that, despite the numerous studies and recommendations, today there is no unanimous viewpoint regarding the level of systolic and diastolic blood pressure in patients with hypertension and diabetes. The concept of “lower is better” hypothesis and J-shaped blood pressure lowering dependence remain competitive and require further study.

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Authors: Svintsitskyy A., Solovyova G., Dynnyk N., Bogomaz V., Baka O.

Introduction. Nonalcoholic fatty liver disease (NAFLD) is considered as one of the most common chronic liver diseases, and among the population of developed countries, this disease occurs in one of three middle-aged people. The aim of this study was to improve the diagnostic algorithm of NAFLD by assessing the capabilities of mod- ern non-invasive diagnosis of steatosis and fibrosis of the liver. Materials and methods. We used the content analysis, method of systematic and comparative analysis in studying the current 73 scientific studies published in English or Ukrainian (PubMed-NCBI, Medline, CochraneLibrary, EMBASE, ResearchGate), of which were selected 25 works which talked about the non-invasive methods of diagnosis with proven high sensitivity and specificity in diagnosis of NAFLD. The results of the analysis are highlighted in the tables. Several non-invasive methods aim at diagnosing and quantifying of hepatic steatosis, while others were designed to predict NASH or significant/advanced fibrosis. The search for the ideal non-invasive test has not been accomplished yet, which explains the vast number of tests available. Imaging techniques, biomarkers and complex models have been studied as tools to predict steatosis, NASH and fibrosis. New methods are usually compared with liver biopsy, that has accuracy far from perfect for NASH and even for fibrosis. For assessing steatosis, US may also be used as comparison, and US cannot detect mild steatosis. In that way, new methods can perform better than the gold standard leading to underestimation of the power of the test. The reliability and importance of the diagnostic tests depend on the disease, the population to which it is applied and the change in management induced by the test’s result. A good screening test should have a high sensitivity even at expense of specificity, whereas a diagnostic test that selects patients for invasive procedures, therapy or clinical trials should have high specificity. Most methods have been evaluated in small pilot studies and have not been externally validated. The majority showed only suboptimal accuracy for NASH. Although discrimination for advanced fibrosis is usually reasonable, no test detects confidently mild/moderate fibrosis. Also, standardization of cut-offs is difficult and most methods lack reproducibility. For the time being, non-invasive tests do not replace liver biopsy, but may avoid it in a large number of cases with low probability or high-risk for having advanced fibrosis/cirrhosis. Ultrasonography still represents the first-line diagnostic tool for simple liver steatosis; its sensitivity could be enhanced by the complex biochemical score SteatoTest. Serum cytokeratin-18 is a promising and accurate non-invasive parameter for the diagnosis of non-alcoholic steatohepatitis (NASH). The staging of liver fibrosis still represents the most important prognostic problem: the most accurate estimating methods are FibroMeter, FIB-4, NAFLD fibrosis score and transient elastography. Conclusions. The calculation of certain clinical and laboratory indices can be used for diagnosis and quantification of the degree of liver damage in patients with NAFLD.