Lviv Clinical Bulletin

8-13

Authors: Shved M., Sydorenko O., Kovbasa N.

Introduction. Atrial fibrillation (AF) is a major public health problem and causes significant financial costs for the health system. Aim. To establish the peculiarities of the clinical course of acute myocardial infarction period in patients with atrial fibrillation and its effect on cardiac hemodynamics and prognosis. Materials and methods. 116 patients with acute myocardial infarction (MI) and non-valvular form of atrial fibrillation, with an average age of 65.82 ± 10.51 years, were examined. Diagnosis was verified according to ESC guidelines (2016). Patients were divided into two groups: the experimental group consisted of patients with MI in combination with AF (66 patients) and the control group – patients with MI without AF (50 patients). Parameters of central and peripheral hemodynamics were determined using doppler echocardiography on the device Philips HD11HE, sensor number S 4-2. Results. The analysis of the data showed that AF in patients with acute MI causes remodeling of the chambers of the heart with the development of aortic dilatation (3.73 ± 0.41 cm, p < 0.01), left atrium (4.49 ± 0.42 cm, p < 0.001), right (2.46 ± 0.55 cm, p < 0.05) and left ventricles (5.4 ± 0.63 cm, p < 0.01) with the decrease of the contractile capacity of the latter (ejection fraction – 40.48 ± 7.57 %, p < 0.01). In turn, it leads to complications of MI, namely, among the surveyed experimental group, cardiogenic shock (21.2 %, p = 0.017) was significantly more common than in patients without arrhythmias (2.0 %) and conduction impairment: acute complete blockade of left bundle branch block (18.2 % vs. 2.0 %, p = 0.014) and acute complete atrioventricular blockade (15.2 % vs. 2.0 %, p = 0.014). It was found that lethality at the inpatient stage of treatment was the highest among those surveyed, in which myocardial ischaemia arose in association with AF and amounted to 7.6 % (p = 0.048) of the observed. Conclusions. Thus, the association of atrial fibrillation with myocardial infarction is marked by the heavier course of the acute period with more frequent development of complications, instability of hemodynamics, conduction disturbances, and pathological post-infarctionventricular remodeling of the heart, which leads to higher mortality and serves as a marker for an unfavorable prognosis.

20-23

Authors: Chopey I., Mykhalko Y., Dukhovych T.

Introduction. S. aureus is the main pathogen of skin, soft tissues and otorhinolaryngological infections as well as the cause of osteomyelitis, meningitis and endocarditis. In recent years the importance of S. aureus mediated infections has grown not only because of their spreading, but also due to their antibiotic resistance. Recent obser­vations showed that the resistance is developed to each new antibacterial agent after 5 years of its intensive use. Based on the studies conducted in Ukraine, it is known that the resistance of S. aureus to fluoroquinolones varies in different regions and ranges from 4.00-6.00 % to gatifloxacin to 45.20-49.00 % to norfloxacin and pefloxacin. Considering that in the overwhelming majority of cases antibacterials are prescribed empirically, an important background for successful antibiotic therapy is taking into account the regional and mostly the local antimicrobial resistance patterns. The aim of the study was to evaluate the antibiotic resistance profile of S. aureus isolates to fluoroquinolones and its changing during 2011-2016. Materials and methods. 355 S. aureus strains isolated from adult patients who were treated in Uzhgorod med­ical institutions due to bacterial tonsillitis or pharyngitis during 2011-2016 were included in the study. After isolation of a pure culture, susceptibilities were tested by using the disk diffusion method. The following antimicrobial disks were tested on Muller-Hinton agar (Biolife, Italy): ofloxacin (5.0 pg), ciprofloxacin (5.0 pg), levofloxacin (5.0 pg), gatifloxacin (5.0 pg), Sparfloxacin (10.0 pg), pefloxacin (10.0 pg), and norfloxacin (10.0 pg). Research methods were used with respect for human rights, according to the current legislation in Ukraine in accordance to international ethical requirements and do not violate the ethical standards in science and standards for conducting biomedical research. Results. Analysis of S. aureus resistance to fluoroquinolones found that this parameter remained at a relatively low level and, in majority of cases, did not exceed 12.00 %. However, constant increasement of antimicrobial re­sistance was noticed during 2011-2016. Thus, the S. aureus resistance to norfloxacin, levofloxacin and ciprofloxacin increased significantly from 0.00 %, 0.00 % and 1.54 % in 2011 to 11.76 %, 13.73 % and 9.80 % in 2016 respec­tively. Resistance to ofloxacin and gatifloxacin in 2011-2016 rised from 3.08 % and 0.00 % to 11.76 % and 1.96 %, respectively, but this difference was not statistically significant. The S. aureus susceptibility to fluoroquinolones fluctuated within 80.00-90.00 % during 2011-2016 and gradually decreased. For instance, susceptibility to norfloxacin, ofloxacin and levofloxacin decreased significantly from 93.85 %, 96.92 % and 100.00 % to 80.39 %, 88.24 % and 84.31 % respectively over the past 6 years. However, for pefloxacin there was a significant increase in susceptibili­ty from 90.77 % to 100.00 % during the investigated period. The prevalence rates of intermediate resistant S. aureus isolates during the study period was negligible and in majority of cases this type of strains were not detected at all. Conclusions. Relatively low rates of resistance and high rates of susceptibility allowed to recommend fluoro­quinolones for the empirical therapy of S. aureus caused infections. However, the gradual increase of resistance to these antibiotics, requires strict compliance with the antimicrobial stewardship.

30-40

Authors: Abrahamovych M., Farmaha M.

Introduction. Syntropic comorbid disorders of the circulatory system in patients with liver cirrhosis are among the most common ones and include two separate diseases: cardiomyopathy with characteristic changes of the heart structure and function; and stable arterial hypotension with its characteristic features of daily blood pressure rhythm and variability, diagnostics of which requires special investigations: echocardiography using doppler, 24-hour blood pressure monitoring, etc. Aim: to distinguish the clinical markers of cardiomyopathy and stable arterial hypotension according to the results of the primary examination of patients with liver cirrhosis. Methods and materials. Complex clinical laboratory and instrumental examination of 603 patients with liver cirrhosis (445 men and 158 women, average age 49.2 ± 10.6 years) was conducted. We distinguished 490 (81.3 %) patients with extrahepatic lesions of the blood circulation system (experimental group that was divided into three subgroups: with syntropic cardiomyopathy separately (103 patients), with syntropic arterial hypotension (89 patients), other (306 patients)), as well as 113 patients (18.7 %) without blood circulation system lesions (comparison group (CG)). The study is dedicated to the statistical analysis with calculation of the chances to put the correct diagnosis of syntropic damages of the blood circulation system using separate indicator: a marker. The research was carried out in four consecutive steps, which included assessment of demographic information, patient complaints, anamnesis and ob­jective review findings. The actual material was processed in the MS Excel and SPSS based on the conjugation tables. The relationships between cardiomyopathy (or arterial hypotension) and the investigated marker were considered to be confirmed, if the modulus of the association coefficient exceeded 0.5 (or 0.3 for the contiguous factor). Results and discussion. According to the first step consisting in the analysis of information from the passport, it was found that gender does not indicate the presence of a syntropic damages of the blood circulation system, unlike the age which can reliably indicate cardiomyopathy (middle and old age) or arterial hypotension (young and mature age). Among the complaints of patients with liver cirrhosis (second task), the pain on the left reliably denies the diagnosis of cardiomyopathy and indicates the presence of arterial hypotension, nausea clearly indicates that the patient does not have stable arterial hypotension. Due to the analysis of the anamnesis of patients with liver cirrhosis (third task),it was revealed that the presence of C-viral cirrhosis (viral etiology) or combined B- and C-viral cirrho­sis (viral etiology) in patients can reliably deny the diagnosis of cardiomyopathy, and the presence of cirrhosis lasting for more than three years, bleedings from varicose veins of the esophagus and/or the presence of virus B-cirrhosis of viral etiology independently of each other can reliably indicate that the patient has stable arterial hypotension. According to the results we received from the fourth step of the research, normal or lower normal body mass index, icteric skin and sclera, weakened heart sounds are associated with cardiomyopathy, and edema on the lower extremities and “caput medusae” – with its absence. Telangiectasias, ascites, “caput medusae”, edema on the lower extremities, hepato- and splenomegaly indicate a stable arterial hypotension. Conclusions. The analysis allows us to confirm that middle and old aged patients have complaints on pain and/or heaviness in the left hypochondrium, if C- or C- and B-viral etiologies of the cirrhosis are absent, body mass index is normal or lower than norm, icteric skin and sclera, weakened heart sounds and “caput medusae” as well as edema on the lower extremities are absent, the presence of cardiomyopathy may be presumed; and in young or middle aged patients there are complaints on pain in the left hypochondrium, nausea, if liver cirrhosis lasts longer than three years, there is information of esophageal varicose veins’ bleedings in anamnesis of the patient, B- viral cirrhosis, telangiectasias, ascites, “caput medusae”, edema on the lower extremities, hepato- and splenomegaly, the presence of the stable arterial hypotension may be presumed. Taking into account clinical markers during examina­tion of the patients with liver cirrhosis makes it possible to form risk groups concerning presence of the correspond­ing syntropic comorbid blood circulation system damages, examine the patient correctly and determine the correct treatment strategy.

46-56

Authors: Drobinska N., Abrahamovych O., Abrahamovych U., Farmaha M.

Introduction. The disorders of calcium-phosphorus metabolism and bone tissue state, which are the main cause of spontaneous fractures and motor activity disorders in patients with liver cirrhosis, they require deeper understanding of etiology and pathogenesis, the use of laboratory-instrumental methods of diagnosis, taking into account risk factors and prescribing of the effective treatment to improve the quality of life. Conducting the additional studies will give impetus to the search for new methods of treatment of not only individual nosolenias, but also co- and polymorbid diseases and will help to reduce the effect of radiation from the use of medications. Aim. To make the literature review devoted to the peculiarities of calcium-phosphorus metabolism and the state of bones in patients with liver cirrhosis, methods of diagnostics and the principles of differentiated treatment, to describe the clinical case. Materials and Methods. The content analysis, the method of system and comparative analysis, the bibliosemantic method of studying the actual scientific studies of the peculiarities of calcium-phosphorus metabolism and the state of bones in patients with liver cirrhosis, methods of diagnostics and the principles of differentiated treatment are described. Results. The review of the literature shows the importance and urgency of the problem of studying calcium-phosphorus metabolism and the state of bone tissue in patients with cirrhosis of the liver. Mechanisms leading to pathological changes in bone tissue in such patients has been insufficiently studied. Nevertheless, there are number of common factors affecting bone metabolism: malformation of calcium and vitamin D, vitamin K deficiency, hormonal disregulation, cytokine release, insulin-like growth factor 1 (IFR-1) deficiency, etc. All efforts in the treatment are aimed at minimizing the loss of bone mass, preventing the fractures and kneading bone pain. First of all, it’s important to persuade the patient to stop smoking and drink alcohol, exercise regularly, and maintain a balanced diet with high levels of calcium and vitamin D. In the described clinical case, the patient with cirrhosis of the liver is diagnosed with osteoporosis confirmed by ultrasound densitometry and examination of calcium-phosphorus metabolism and bone tissue state by measuring the content of total calcium, ionized calcium, phosphorus, vitamin D, parathyroid hormone and markers of bone metabolism (b- crossLaps, P1NP, osteocalcin). Conclusions. The study of the state of calcium-phosphorus metabolism and the state of bone tissue in patients with liver cirrhosis requires the use of safe and informative diadynamic methods that will be used at any stage of the disease and will help in choosing the therapeutic tactics.