Lviv Clinical Bulletin

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.