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.

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.

58-64

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.

14-18

Authors: Zadorozhna B., Shevaga V., Semchyshyn М.

Introduction. The problem of pathogenesis of craniocerebral trauma (CMT) is relevant in modern medicine. Particular attention is paid to the search for biochemical markers, due to the impossibility of holistic explanation of the occurrence of all the pathological manifestations of brain damage only due to its mechanical damage. One of such areas may be the study of mineral homeostasis, in particular, the exchange of copper. Aim. To study the level of trace element of copper in the blood serum of patients in the brain injury of mild and moderate severity and in soldiers of anti-terrorist operation with mine explosive brain injury during acute and intermediate periods. Materials and methods. Complex examination of 283 patients with brain injury of mild and moderate severity in acute and intermediate periods was carried out as well as of 218 soldiers of anti-terrorist operation with mine explosive craniocerebral trauma. 20 almost healthy volunteers made the control group for patients of a peaceful time and 20 soldiers of anti-terrorist operation with politrauma – for patients with mine explosive brain injury. The level of trace element of copper in the serum of blood was investigated by means of atomic – absorption spectroscopy. Results and discussion. The concentration of copper in the serum of blood examination on the 1-2, 3-5, 7-10, 14-21 days, and in 1 month after the trauma was found out. Analysis of the results examination show, that with all patients with brain injury on peaceful territory the concentration of copper in the serum of blood was reliably higher (p < 0.05) as compared with the control group during all the period of observation. The highest degree index was observed in patients with cerebral contusion of mild degree, the lowest – in patients with cerebral concussion. Critically high levels of copper were observed on 3-5 and 7-10 days, but in 1 month after trauma it reduced, however remained quite higher (p < 0.05) than the index in the comparison group. Analysis of dynamics changes of the copper concentration in soldiers of the anti-terrorist operation show, that in all the soldiers´ blood serum the contents of copper was significantly higher during all the observation period, as compared with the control group (p < 0.05), and also as compared to the received facts in the other group (р1 < 0.05, р2 < 0.05, р3 < 0.05). The essential difference in the contents of copper in the serum of blood was observed in the soldiers with cerebral contusion of mild severity and cerebral contusion of moderate severity, lessened by the cerebral concussion. Area of results application. Neurology. Conclusions. High indices of copper concentration in the serum of blood indicates about the vessel pathology and causes oxidative stress, that is a factor for sclerosis cerebral vessels.

22-27

Authors: Leontyeva S.

Introduction. The prevalence of Raynaud’s syndrome in different countries ranges from 2.1 – to 16.8 %. Secondary Raynaud’s syndrome (SRS) occurs in case of more than 70 diseases. However, there is no consensus about the pathogenic mechanisms of its origin, and the modern diagnosis algorithms, without which it is difficult to choose the correct treatment that influences the patients’ disability prognosis and his life quality, are not elaborated. The purpose of the study is to ascertain the clinical and pathogenetic peculiarities of SRS of different severity degrees, to work out the algorithms for its diagnosis and increase the effectiveness of treatment with candesartan. Materials and research methods. The work is based on the results of the survey of 120 patients with SRS. The diagnosis of SRS is carried out using the criteria of E. Allen, G. Brown. Statistical analysis was performed using the package STATISTICA for Windows 5.5 (Statsoft, USA). Results of the investigation and their discussion. Among the 120 surveyed patients there were 101 women and 19 men, average age – 48,5 (17,0–73,0) [34,0–56,0] years in the ratio of 5:1. The first group consisted of 44 (36.7 %) patients with mild severity. In this group were observed the skin colour changes with minimal subjective disorders, such as numbness or tingling while infrequent episodes of vasospasm without trophic changes have occurred. It was found, that the mild course of SRS was characterized by the absence of the visible changes of the major humoral factors of vasodilatative and vasoconstrictive action (ET-1, AT II, ​​6-keto-PG F1α) before the start of pharmacological correction. The method of widefield capillaroscopy revealed angiodystonic changes of capillaries in such patients. The second group of patients consisted of 53 persons (44.2 %) with moderate severity of SRS, that was characterized by the presence of attacks, mainly in the cold season, with more pronounced than in the first group subjective disorders such as tingling or pain in fingers with manifestations of trophic changes in most of them. Changes of the humoral vascular tone regulators in this group were more pronounced than in the group with mild severity, and primarily were characterized by the elevated levels of both ET-1 and AT II, comparing to the control group. During the capillaroscopic examination in patients with the moderate severity degree of SRS, there were found similar changes as in the patients of the first group, but with a reduction of the capillary net. The third group consisted of 23 patients (19.2 %) with severe severity degree of SRS, that was characterized by the frequent bouts of vasospasm and was accompanied by severe pain, with the presence of digital scars, single ulcers and atrophic changes of the phalanges. The indices of the humoral regulation factors in patients with severe SRS were characterized by the considerably pronounced growth of ET-1 and AT II. In severe course of SRS, the vasoconstrictor response was more pronounced, that was confirmed by the high performance levels of humoral regulators of the vasoconstrictor action. There were found pronounced capillaroscopic changes: spastic and atonic state of capillaries, resize and form changing of the capillary loops, reduction of capillary grid, the presence of megacapillaries and non-vascular fields, local ischemia, an acute deceleration of the blood flow, venous stasis. These indices were studied in the patients in dynamics after the treatment with candesartan during one and four months (short-term and long-term courses of treatment). For the patients there was conducted written survey within a month using a questionnaire, which showed subjective improvement of the clinical status of respondents with moderate and severe courses of SRS. Whereas we studied the pathogenic features of SRS and their clinical parallels, pathogenetic correction with candesartan, proposed by us, had a positive influence, that manifested in the decrease of the amount and duration of SRS attacks, the intensity of pain according to VAS, significant strengthening of vasodilatation (increase of 6-keto PG F1α), decrease of ET-1 and PG F2α levels, slowing the proliferative processes, increase of prostacyclin and its active metabolites levels, that, in its turn, increases the positive influence effect on the blood vessels. The mentioned effect of treatment found confirmation in the results of ultrasonography examination, during conducting of which the reduce of the peripheral vascular resistance was seen. In our view, this can be explained by the property of candesartan to influence the arterio-venous shunts, that have a direct impact on the properties of compensatory peripheral resistance. Conclusions. The study found an advantage of vascular tone humoral regulation factors of vasoconstrictive action, such as ET-1 and AT II, increased antinuclear factor level that are directly proportional to the increase of the disease severity degree of the mentioned pathology, and the presence of the asymmetry coefficient elevation in case of the mild SRS, changes of the reosystolic index and “intima – media” complex. The least pronounced clinical signs were observed in patients with neurocirculatory dystonia and essential crioglobulinemic vasculitis and were characterized by the mild severity degree, whereas in case of systemic scleroderma systemic lupus erythematosus and rheumatoid arthritis there were dominated the moderate and severe degree of its course. The conducted by us pathogenetic correction of SRS with candesartan favorably influenced, in the first place, the state of the bloodstream of the upper limbs at all clinical degrees of its severity. These positive changes were confirmed by the data obtained from the patients’ questionnaire, that showed the reduced levels of pain in case of the moderate and severe course, according to VAS, and the index of attacks’ duration in case of severe course of SRS.

34-38

Authors: Kurgan M., Kokoruz M., Kurgan D., Novak V.

Introduction. The passing of some obstetric complications, intravascular haemolysis and destructive traumas are complicated by the syndrome of disseminated intravascular coagulation (DIC). DIC is caused by presence of thromboplastin (T) in the blood flow – pieces of cytoplasmic membranes or substances that are extracted from membranes. T causes formation of trombin, plasmin, kallikrein by activation of XII factor of heamocoagulation system. The activation of these enzymes disturbs the haemostasis system. It is known, that beginning of DIC is the phase of hypercoagulation with formation of disseminated microthrombosis. It activates the processes of fibrinolysis. The blood loses the ability to coagulate, and it is the phase of hypo-coagulation. As a result, haemorrhage, hypotension, thrombocytopenia appears. Aim. To investigate the dependence of clinical manifestations of DIC on the degree of dispersion of infused thromboplastin, as well as the effectiveness of its treatment with heparin and plasmapheresis. Materials and methods. It is ascertained that hyper-, hypocoagulation in case of DIC depends on the grade of dispersion of thromboplastin, which enters in bloodstream. It is proved, that pieces of cytoplasm membranes were shrouded by fibrin and platelet during 15-20 seconds after infusion. Fibrin-monomer and platelets adhere to the surface of pieces of cytoplasm membranes, which are recognized as ″alien″ and montage fibrin polymer. As a result, there is a formation of blood microthrombuses. The surface aria of the extractive substances T wasn`t sufficient for such montage and plasmin lyses free molecules of fibrin-monomer to degradation products (DP). DP has the anticoagulation properties and cause hypocoagulation and bleeding. Bradykinin, synthesized under kallikrein, causes hypotonia. Heparin, given bolus intravenousny in dose 300-350 U/kg of body mass, inhibited the activity of trombin, plasmin, kallikrein, DP, bradykinin. Results and discussion. It was found out that the manifestations of hyper-, hypocoagulation in case of DIC depended on the degree of dispersion of T. The microtubes arose due to sticking to the “other” surface of the cubes with the fibrin-monomer (FM) and platelets. The surface area of ​​the extracted substances T was insufficient to stick to the FM molecules, and plasmin lysed them to degradation products (PDP). As anticoagulants, PDP caused hypocoagulation, bleeding. Bradykinin, formed by the action of calicreatin, predisposes hypotension. Heparin, injected intravenously bolus dose of 300-350 OD / kg of body weight, inhibited the activity of thrombin, plasmin, calicreatin, PDP, bradykinin. The blood flow T was removed by plasmapheresis. Conclusions. Heparin infusion stopped lysis of platelets, bleeding, normalized the blood pressure in clinical cases. The symptoms of DIC completely disappeared, clinical status of patients returned to normality.

42-47

Authors: Pekhenko V.

Introduction. The ratio of spontaneous vs. induced NBT-test neutrophils and monocytes is a reliable diagnostic criterion for evaluating the functional capacity of cells in the system of natural resistance. Thus the goal of our research was to determine the functional activity of phagocytic peripheral blood cells and changes in such activity under the influence of treatment in patients diagnosed with rheumatoid arthritis (RA), combined with arterial hypertension (AH). Aim. To determine the functional activity of phagocyte cells of peripheral blood and its changes under the influence of treatment in patients with RA, combined with AH. Materials and methods. 89 patients with RA and hypertension (25 male, 64 female, aged 35 to 65 years), were included into the research, after obtaining informed consent. All patients, (depending on the degree of RA activity), were stratified into three groups, which were accordingly prescribed different therapeutic complexes. The first group included 32 patients (8 male, 24 female, aged 36 to 65 years) with a minimum RA activity level (as DAS 28 < 3.2) who received methotrexate at a dose of 7.5 mg a week, an exacerbation glucocorticoids were administrated in initial dose of 15,0-20,0 mg with gradual reduction of 2.5 mg per week and remained at a maintenance dose of 2.5 or 5.0 mg till the end of the study. The second group consisted of 30 patients (10 male, 20 female, aged 36 to 65 years) with a third-level active RA (index DAS 28 > 5.1), which had negative Mantoux test reaction, (i.e. they had no contraindications to use “Remiсade”) and who had received methotrexate at a dose of 7.5 mg a week and “Remiсade” at a dose of 3 mg/kg in/drip through infusomat at the beginning of treatment, then in 2 weeks, again in 6 weeks, and then every 8 weeks for 6 months; The third group was composed of 27 patients in total (7 male, 20 female, aged 35 to 64 years) who had a third- level active RA (index DAS 28 > 5.1), but had contraindications to use “Remiсade ” (due to positive Mantoux test) and therefore they received methotrexate from 15.0 mg (by 5.0 mg x 3) to 22.5 mg (7.5 mg x 3) a week. Because the patients from the 2-nd and the 3-rd group had a third-level active RA, all of them also received an initial dose of glucocorticoids of 30,0-40,0 mg with further gradual reduction by 5.0 mg per week before the maintenance dose of 7,5-10, 0 mg was reached. Results and discussion. Clinical effectiveness and safety evaluation of a therapy based on fixed combination of amlodipine and lisinopril (drug “Equator”, OAO “Gideon Richter” Hungary) had demonstrated its high efficiency in the treatment of RA patients with hypertension. The comparative analysis of functional activity of neutrophilic granulocytes(FANG) and functional activity of monocytes (FAM) of patients in first and second groups vs. patients from third group made it possible to conclude that the use of adequate treatment allows to retain the functional activity of phagocytosed cell (for patients of the first and second groups) adaptive at a minimum level in response to microbial antigens E.coli. Under these conditions, the preservation of functional ability of monocytes, as the main link of immune system’s antigen cells presentation, reduces the formation of immunosuppression and autoimmune reactions in patients of first and second groups. These trends were less vivid in patients of the third group. Conclusions. Thus, if the adequate therapy for RA is prescribed, the functional activity of phagocytosed cells is retained in the adaptive minimum level, and the preservation of functional ability of monocytes, as the main link of immune system’s antigen cells presentation, reduces the formation of immunosuppression and autoimmune reactions.

56-64

Authors: Abrahamovych O., Fayura O., Abrahamovych U.

Introduction. Researches of the famous scientists proved, that comorbid diseases often worsen the course of the underlying disease and/or lead to its chronicity, cause disability and premature death of the working population, often make inefficient diagnosis and treatment, increase the costs of the health system to provide medical care. According to the research of WHO experts, people under 40 usually have 2-4 diseases, under 60 – there is a “bouquet” of 5-7 diseases, after 70 – 8-10 or more diseases. So-called “polymorbidity” increases from 10.0 % in patients aged <19 years old to 80.0 % in patients aged >80 years old. Materials and research methods. The work analyzes the literature sources, which deal with the study of comorbid diseases and sufficiently thoroughly reflect the current views of the scientists on the issue. Results of the investigation and their discussion. There are many synonyms of the term “comorbidity”, among them, often are used the following: “polymorbity”, “multimorbidity”, “multifactorial diseases”, “polypathy”, “multicausal diagnosis”, “dual diagnosis”, “pluripathology” etc., which complicates the understanding of the problem and minimizes the ability to use scientific achievements in clinical practice. In Ukrainian literature the authors often use the term “bicausal diagnosis” to describe comorbidity when there are two underlying diseases, to describe polymorbidity – “multicausal diagnosis” (three or more pathological conditions in one individual). In English scientific literature the authors often use the terms “comorbid diseases”, “comorbid conditions”. In general, the sources of information, used by the researchers to study the problem of polypathies, were and are medical histories, hospital records of the patients and other medical records of family doctors, of insurance companies, archives of the pensions for the elderly. Comorbidity itself can be interpreted as a random combination of the diseases, different by its’ etiology and pathogenesis such as nosological syntropy, ie natural occurrence of the regular determined diseases combinations in one patient. The main causes of comorbidity are: affected organs anatomical proximity, common pathogenesis, causal connections, combination of the diseases or iatrogenic causes. Among the factors, that influence the occurrence of comorbidity in humans, is a chronic infection, inflammation, involutive and systemic metabolic changes, iatrogenic factors, social status, environment and genetic predisposition, and the main way of the development of comorbid disorders is causal. The appearing of a particular disease leads to functional first, and later – to organic lesions and further – to an increase of nosologies quantity. Despite the large number of studies, proposed definitions and synonyms, standardized terminology and conventional classification of comorbidity, that would greatly help in the study of its problems, until now is missing. Conclusions. Despite many unsolved patterns of comorbidity and lack of the unified terminology, the search for the new variants of combinations of these diseases continues. After all, they can simply be not yet classified syndromal diseases, or vice versa – to be completely incompatible for the appearance and coexistence in one body. This is the key to solve more and more problems for the diagnosis and treatment of the diseases in the field of the practical medicine.

15-20

Authors: Perebetyuk L.

Introduction. Rheumatoid arthritis (RA) is one of the most common inflammatory joint disease, with a progressing severity and high disability. It is often combined with fibromyalgia (FM), which can modify its course. The prevalence of primary FM among adults is on average 2.0-3.0 %, with prevalence of females and peak age of 55-64 years. In recent years, the principles of diagnosis of FM have been revised, along with the traditional criteria ACR1990 the modified criteria mACR2010 were proposed, but there is practically no experience with their use in patients with RA. Aim. To find out the clinical features of patients with RA associated with FM, and the possible association of the course of the disease with FM markers according to the criteria ACR1990 and mACR2010. Materials and methods. 125 patients (100.0 % female) with RA were included in the study. In 46 of them RA was associated with FM. Mean age of the patients under investigation was 49.6 ± 12.8 years. The diagnosis RA was established by ACR/EULAR-2010 criteria, the diagnosis FM was established regarding ACR1990 and modified ACR2010 criteria. RA activity was evaluated by DAS28 and CDAI, functional status – by HAQ. The diagnosis of FM was given in the case of detecting at least 11 (out of 18) specific sensory points (CP ≥ 11) and 13 (from 31) on the scale of fibromyalgia (SF ≥ 13) in patients with RA. Specific CPs were determined by pressing with a finger at them with a force of 4 kg/cm2 (to the effect of whitening of the nail bed of the researcher) and were considered positive if the patient felt pain. Results and discussion. By the evaluation of clinical features of patients in which the rheumatoid arthritis (RA) was associated with fibromyalgia (FM) it was found that these patients had a higher disease activity by DAS28 and CDAI (OR = 13.3, 95% CI 4.41, 40.3). Significant violations of the physical function (HAQ>2) were found in 40.0 % of RA patients associated with FM, and in 19.0 % of patients with isolated RA. In the presence of FM in patients with RA the difference between the number of tender and swollen joints was 3.16 times higher and significantly correlated with the markers of the central sensitization (number of tender points fibromyalgianess scale). FM frequency was higher among the patients with seronegative RA (OR = 2.90, 95% CI 1.36, 6.21). Phenotypic features of patients with RA suggest the need for modification of diagnostic and therapeutic measures in patients with a fibromyalgic variant of the disease. Conclusions. FM is an independent factor that modifies the clinical course of the RA, causes an increased disease activity by DAS28 and CDAI, significantly impairs physical function for the RA patients.

27-31

Authors: Pankiv І.

Introduction. Bone density measurements during the last decade have demonstrated that bone loss is common in patients with overt hyperthyroidism and to a lesser extent in those with subclinical hyperthyroidism, whether caused by nodular goiter or excessive doses of thyroid hormone. Overt hyperthyroidism is associated with accelerated bone remodeling, reduced bone density, osteoporosis, and an increase in fracture rate. The bone density changes may or may not be reversible with therapy. These changes in bone metabolism are associated with negative calcium balance, hypercalciuria and, rarely, hypercalcemia. Aim. To investigate frequency and structure of bone disease in patients with thyrotoxicosis, and also to find out the features of clinical manifestations of osteoporosis, taking into account the duration of disease. Materials and methods. 65 patients with thyrotoxicosis syndrome were included. The bone density based on the T-score of femoral neck and lumbar vertebrae were compared between three groups. For densitometry, dual-energy X-ray absorptiometry was used to measure the bone density in lumbar vertebrae (L1–L4, anterior-posterior measurements) and femoral neck. The measurement was performed by an expert technician using densitometer Lunar Prodigy Primo, General Electric, USA. A complete set of data was collected for each patient and include: Patient’s age, history of hypothyroidism or other chronic diseases, weight, height, body mass index (BMI), T-score data of lumbar, and femoral neck densitometry, calcium, phosphorus, alkaline phosphatase, Vitamin D and TSH levels and duration of hypothyroidism. The Ethics Committee of the Bukovinian State Medical University approved this study, and a written informed consent was obtained from all study participants. Data of 65 individuals was analyzed using the regression analysis, analysis of variances and Mann-Whitney (for non-parametric quantitative data) tests. Continuous variables were summarized using means and standard deviation; frequencies and percentages were used to summarize categorical variables. A p < 0,05 was considered statistically significant. Results and discussion. Indexes of bone mineral density was decreased, and frequency of osteoporosis and osteopenia was higher as compared to population indexes in persons of corresponding age. Osteoporosis in one of two basic localizations is lumbar department (L1–L4) and proximal femur was found in 4 patients (6.2 %), osteopenia – in 29 (44.6 %). On the whole the decline of bone mineral density was observed in 33 (50.8 %) patients. Correlation analysis showed statistically significant negative correlation between mineral bone density and age of patients (r = -0.42, р < 0.05), and also weak correlation with the thyrotoxicosis duration (r = -0.18; р < 0.05). Positive correlation was found between mineral bone density and height (r = 0.27; р < 0.05), body mass index (r = 0.29; р < 0.05), and also between the free thyroxine level and mineral bone density (r = 0.19). Conclusions. The expressed unfavorable influence of thyroid hormones high levels is set on bone mineral density. Analysis of bone metabolism markers showed the acceleration of bone resorption. There were significant correlation between the free thyroxine high levels and the markers of bone mineral density. Duration of thyrotoxicosis syndrome had negative correlation with indexes of bone mineral density. During thyrotoxicosis decompensation there is an acceleration of bone exchange, that was.

36-41

Authors: Barilka V., Matlan V., Prymak S., Vygovska O., Shalay O.

Introduction. Myelosuppression with severe anemia or thrombocytopenia refers to the adverse factors in clinical course of B-cell chronic lymphocytic leukemia (B-CLL). According to the existing data, in B-CLL patients (pts) the production of TNF and its soluble receptors, such as sTNFRI and sTNFRII, is broken. However, the final role of these proteins in myelosuppression developing in B-CLL pts is studied poorly. Purpose of the study. To determine the role of TNF, sTNFRI and sTNFRII in myelosuppression, developing in case of B-CLL. Materials and research methods. Determination of tumor necrosis factor (TNF) and its soluble receptors, such as sTNFRI and sTNFRII, was performed using blood plasma of 74 pts with B-CLL at different stages of the disease before treatment. Determining the concentration of TNF was carried out by the biological methods, using mouse fibroblasts cell culture line L929. The level of sTNFRI and sTNFRII was performed by immunological methods using the kits of BioSource Europe S. A., Belgium. These parameters were analyzed in relation with complete blood counts of the pts with B-CLL. The control group consisted of 15 healthy blood donors. Probability statistics was evaluated using Student’s t-test. The relationship between the concentration of TNF, sTNFRІ, sTNFRІІ and haemograms of pts at different stages of B-CLL was established by the correlation coefficient (r), which was calculated by Excel program. Results of the investigation and their discussion. The significantly higher levels of TNF (0.938 ± 0.124 ng/ml) and sTNFRII (32.180 ± 4.350 ng/ml) in plasma of B-CLL pts at all stages of the disease compared to healthy donors (0.089 ± 0.017 and 4.170 ± 0.231 ng/ml, accordingly) were established. On the other hand, appreciably lower levels of TNF and sTNFRII in plasma of B-CLL pts at early stage in comparison with more advanced stages were determined. The concentrations of TNF and sTNFRII correlated negatively with hemoglobin level and red blood cell count, but positively with absolute lymphocytic count at the early stage of the disease. In addition, any changes were detected in TNF, sTNFRI and sTNFRII concentrations in patients with thrombocytopenia. Conclusions. These studies suggest that increasing of the concentration of TNF, sTNFRI and sTNFRII in case of B-CLL, as a result of their production by leukemic cell, may adversely affect hematopoiesis and induce development of anemia in pts with B-CLL. Thus there was installed a possible negative role of accumulated levels of TNF and sTNFRII in plasma of the pts with B-CLL in occurrence of bone marrow suppression at early stages of the disease. In advanced stages of B-CLL, the levels of the secreted TNF, sTNFRII may contribute to leukemic progression, which is confirmed by the high correlation between both indices. In addition, we didn’t found significant changes in concentration of TNF, sTNFRI, sTNFRII in pts with varying content of platelets which pointed to the likely involvement of cytokines, other than TNF, sTNFRI, sTNFRII in the regulation of megakaryopoiesis in pts with B-CLL. So, determination of TNF and its soluble receptors may be used to predict the development of anemia as well as to initiate the treatment in B-CLL pts.

46-50

Authors: Smolyar N., Fuhr N.

Introduction. Publications of the last years demonstrate the growth of malocclusions prevalence along with other main stomatological diseases. The researches carried out in different regions of Ukraine revealed some regional and age peculiarities of malocclusions prevalence. Formation of the orthodontic pathology has polyetiological genesis and is the result of endogenous and exogenous factors. Among the risk factors that influence their formation the most important are the biological, environmental, hereditary, natural, geochemical and especially social – domestic, because the standard of living and nutrition, living conditions, even family atmospheres ignificantly influence the state of health, including dental health. Orthodontic pathology which is not detected and not cured at the stage of the temporary and mixed dentition, becomes more expressed and severe in permanent dentition. That’s why their early detection is very important in children at the stage of temporary dentition, when dentoalveolar system is under constant growth. The elimination of risk factors in time of the initial manifestation of the disease can provide the normalization of development, and the study and analysis of prevalence malocclusions among children of different groups becomes the basis for forecast and prevention of severe forms of malocclusions. Particular interest in this aspect is the study of the basic indices of the prevalence and structure of malocclusions in children who live and study in the boarding schools, taking into consideration the fact that these children drop out of sight of doctors-orthodontists. Purpose of the research – assessment of the prevalence and structure of orthodontic pathology in children from boarding schools. Materials and research methods. An epidemiological survey of 528 children from boarding schools of Lviv and Lviv region (main group) and 122 secondary school children (control group) at the age of 7, 9, 12 and 15 years. The results were recorded in a specially worked out cards. Classification of D. Kalvelis was used to verify the diagnosis of malocclusion. The results of the research were statistically processed using the Student’s test. Results of the investigation and their discussion. The results of the investigation showed that the prevalence of malocclusions in children from the main group is 84.09 ± 1.54 %, and in children from the control group – 66.39 ± 4.28 %. Analysis of the received results showed that with the age the number of children with maloccluisons increased. So, the malocclusions prevalence in children from the main group increases up from 80.45 ± 3.44 % in 7-year-old children to 87.90 ± 2.93 % in 15-year-old children. However, malocclusions prevalence in children from the control group increases from 61.29 ± 8.75 % (in 7-year-old children) to 76.67 ± 7.72 % in 12-year-old children (it’s the peak of prevalence). Further up to 15 years is noticed the decrease of malocclusion prevalence in children (to 58.62 ± 9.15 %). Anomalies of the dental arches were diagnosed in 77.08 ± 1.83 %, anomalies of individual teeth – in 16.67 ± 1.62 %, anomalies of occlusion – in 41.86 ± 2.15 %. No child with maloccluions from boarding schools, was under orthodontic treatment. The analysis of the malocclusions structure of surveyed children according to the age showed that the incidence of abnormalities of the dental arches was at a high level, ranging from 70.68 ± 3.95 % to 80.65 ± 3.55 %. Otherwise, was fixed the growing of prevalence of anomalies of occlusion at the age from 7 to 15 years from 33.08 ± 4.08 % to 49.19 ± 4.49 %, because of the lack of self-regulation processes and the lack of orthodontic treatment. However, up to 12 and 15 years we have seen the growing of prevalence of anomalies of the individual teeth to 16.67 ± 3.17 % and 23.39 ± 3.80 % respectively. However, already at the age of 12 years, when the self-regulation should take place, the prevalence of all forms of malocclusions is increased, and in the age of 15 years the prevalence of anomalies of individual teeth in children from boarding-schools reached 23.39 ± 3.80 %, prevalence of dental arches – 80.65 ± 3.55 % and anomalies of occlusion – 49.19 ± 4.49 %. Conclusions. In our opinion the increase of malocclusion frequency in children of the main group with age is due to the absence of orthodontic treatment, as well as to the absence of self-regulation processes. The obtained results underline the necessity of the further researches on the subject of the main features of the main stomatological diseases in children with malocclusions, who study and live at boarding schools.

55-60

Authors: Chooklin S., Pidhirnyy B., Chuklin S.

Introduction. Heparin is a glycosaminoglycan composed of chains of alternating d-glucosamine and uronic acid residues. Its major anticoagulant effect is attributed to a unique pentasaccharide structure. Heparin prevents coagulation after binding with a plasma antithrombin III. Antithrombin III is a protease inhibitor and complex heparin antithrombin III inhibits activity of thrombin, as well as neutralizes active forms of factors IX, X, XI and XII. However, the most important action of heparin is not inhibition of thrombin activity, but inhibition of thrombin creation, especially through accelerating the neutralization of factor Xa. In large concentration, heparin combined with antithrombin III also inhibits platelet aggregation. Aim. To analyze the mechanism of action of heparin and its application for the treatment of patients with acute pancreatitis. Materials and methods. Content analysis, method of system and comparative analysis, bibliosemantic method of study of actual scientific researches concerning the mechanism of action of heparin and its application for the treatment of patients with acute pancreatitis was used. Results. In various experimental and clinical studies, heparin has been found to exhibit the anti-inflammatory activity. Heparin has shown protective and therapeutic effect in patients suffering from a range of inflammatory diseases, including rheumatoid arthritis, bronchial asthma, allergy and ulcerative colitis. The heparin-antithrombin III complex significantly reduces the activity of trypsin and chymotrypsin. There are experimental and some clinical studies showing protective and therapeutic effect of heparin in the pancreas. Experimental data indicate that pretreatment with heparin inhibits the development of acute pancreatitis evoked by bile, taurocholate, cerulein, or pancreatic ischemia followed by reperfusion. There are also experimental studies showing therapeutic effect of heparin in the course of acute pancreatitis. Clinical reports concern mainly the role of heparin in the prevention of acute pancreatitis due to endoscopic retrograde cholangiopancreatography and treatment of acute pancreatitis evoked by hyperlipidemia. Conclusions. The administration of heparin enhances the effect of conventional treatment of severe acute pancreatitis, markedly decreases the incidence of encephalopathy and improves the survival rate in patients with this disease. Due to the anticoagulation and anti-inflammatory properties, accessibility, ease of use of low molecular weight heparins they can be included in the complex treatment of patients with severe pancreatitis, especially at an early stage of the disease, for the purpose of prevention and correction of organ dysfunction.

14-18

Authors: Kеch N.

Introduction. One of the decisive mechanisms of the influence of xenobiotics on a human organism is the disturbance of calcium-phosphorous homeostasis and oxidative metabolism of cells due to the changes in the intracellular flow of calcium (Ca) and phosphorus (P), their replacement on specific receptors, and subsequent activation of calcium-dependent enzymes and hormones. Even in the case of short hypoxia, and during the action of xenobiotics, prolonged tissue hypoxia occurs, homeostasis of such trace elements as Na+, K+, Ca++, P+++, Mg++, Mn+++, Cu++ and Fe++, that correlates with the decrease of the level of intracellular ATP and the activity of most metal enzymes. Aim. To find out the effectiveness of advanced standard treatment of lesions of the bone system in children from ecologically disadvantaged areas (EDAs) based on the study of calcium-phosphorous homeostasis and mineral density of bone tissue. Materials and methods. We investigated 239 children from ecologically polluted regions and 70 children from ecologically clean area. Children’s age is from 3 to 18 years, sex – 48, 0 % boys and 52, 0 % – girls. Level of calcium and phosphorus in the blood and urine in these children before and after the treatment was analyzed by the biochemistry examination. Bone mineral density and bone system degree of changes were measured by ultrasound densitometry. Results. Level of calcium and phosphorus in the blood in observed children from polluted region was reduced. Level of calcium in the urine was increased in the majority of observed children from the radiation polluted region and in children from the chemistry polluted regions. And level of phosphorus in the urine was increased in the majority of observed children from chemistry polluted regions. The level of the bone mineral density in these children was reduced. Indicators of calcium and phosphorus content in blood and urine and bone mineral density in the examined children after a complex, individually selected treatment were normalized. Indicators of bone mineral density of children from all EDAs irrespective of the nature of contamination and ways of getting xenobiotics into the organism, have significantly decreased and are within the age range compared with the indicators of healthy children after the treatment. Conclusions. In the majority of the examined children in radiation and chemically contaminated areas there was a significant hypocalcemia, hypophosphatemia and hypercalciuria, hyperphosphaturia, which managed to be corrected by the proposed treatment.

23-25

Authors: Kapustуnskа О.

Introduction. Since cholesterol is a substrate for the synthesis of sex hormones, including testosterone, changes in androgen availability in patients taking statins can be expected. At the same time, the effect of statins on androgenic provision of patients with coronary artery disease was studied selectively, mainly in males. In particular, published single reports of a decrease in total testosterone (TT) in men taking statins. Aim. To investigate the status of androgen support in patients with stable angina pectoris (SAP) in combination with type 2 diabetes mellitus (DM) and its modifications under the influence of statin treatment. Materials and methods. The effect of statin treatment on the indices of androgen availability of 120 SS patients in combination with DM type 2 on the basis of determination of the TT, testosterone-estradiol-binding globulin and free androgens index (FAI) was analyzed. Among the patients with SAP in combination with DM type 2, 53 (44.17 %) men and 67 (55.83 %) women. The average age of patients was 60.10 ± 0.78 years (57.85 ± 1.12 years – males and 61.88 ± 1.03 – females). SAP diagnostics were conducted in the accordance with the recommendations of the European Association of Cardiologists for the management of patients with stable coronary artery disease (2013), type 2 diabetes – the recommendations of the European Diabetes Policy Group and WHO (2011). Results. It demonstrates the definition of the levels of TT, testosterone-estradiol binding globulin (TEBG) in plasma and free androgen index calculation (FAI) = TT•100/TEВG. The androgen imbalance was studied and established that an average TT in men with SA in conjunction with type 2 DM was significantly reduced. It was determined that in women with SA and type 2 diabetes were increase both statins and FAI. In both men and women in the main group was established a decrease of TEВG in comparison with the control patients (p = 0.009 for men and p = 0.05 for women). The effect of the treatment with statins on the androgenic provision indicators was dose-dependent. Both men and women receiving high-dose statins showed a reduction in the average level of TT and FAI. In patients treated with statins in standard doses a significant impact on the androgenic provision indicators was not found (p > 0.05). Conclusions. In men with with type 2 DM, the SS passes with a decrease in TT level. The use of high doses of statins deepens the androgen deficiency (reduces the rates of TT and IVA). In women with DM, SS is accompanied by an increase in TT and IVA. The appointment of statins to patients with DM type 2 in combination with CC, corrects the androgenic imbalance.

30-36

Authors: Abrahamovych U.

Introduction. Vegetative disorders are a term that unites varieties of origin and manifestations of the violation of vegetative functions of the organism, which are caused by the disorders of their neurogenic regulation. Regarding the pathogenesis of the autonomic nervous system (NS) dysfunction in the presence of systemic lupus erythematosus (SLE), there are several hypotheses: the occurrence of vasculitis with the involvement of vessels of the nerves, or secondary amyloidosis; the influence of immunological factors, in particular, circulating antibodies to the structures of the NS were detected. However, none of them has a definitive confirmation. The aim of the study was to describe the autonomic NS state in the patients with SLE with the different activity degree of the disease according to the heart rate variability indices. Materials and methods. 83 patients were examined. Among them, 65 women (78.3%) and 18 men (21.7%) aged 18 to 74 years (mean age 44.2 years), who were diagnosed with SLE according to the criteria of the American College of Rheumatologists (1982, 1997). Patients are divided into three groups according to the randomized principle with pre-stratification on the activity of the pathological process of the underlying disease – SLE at the time of the heart rate variability (HRV) conducting: the first group – with the first degree of activity, the second group – with second degree of activity, the third group – with the third degree of activity. There were also 40 practically healthy persons (27 women (67.5%) and 13 men (32.5%)) aged 19-70 years old (mean age 41.8 ± 4.2 years), of which the control group was formed. Recording of the HRV was performed for 5 minutes in the lying position (state to the physical activity) and for 6 minutes in standing position (after physical activity, orthostatic test). Results. The value of the heart rate allows to characterize the balance between the tone of the sympathetic and parasympathetic parts of the autonomic NS, since the change in the heart rate is a universal reaction of the organism to various stimuli of the internal or external environment. The state of the autonomic NS in patients with SLE with varying degrees of activity is characterized by a decrease in the total activity of vegetative effects on the heart rhythm due to the reduction of sympathetic and parasympathetic effects, as well as the humoral component. Conclusions. Based on the reduced total spectral power in patients with SLE, an unbalance of the autonomic NS is observed due to the predominance of the sympathetic NS, especially expressed in the sample before the physical activity.

41-46

Authors: Grechkivska N.

Introduction. The problem of cardiovascular diseases is one of the most important in medical science and practical public health. The most urgent problem of hypertension is in groups of working population suffering from the harmful factors of production environment and labor process such as noise, vibration, harmful industrial climate and so on. Aim. To develop the criteria of professional competence of employees with hypertension working under the harmful and dangerous factors of production environment and labor process. Materials and methods. The analysis of general and occupational diseases were carried out on the results of periodic medical examinations of individuals working under the influence of the hazardous and dangerous conditions on the basis of the general medical reports. The analysis was provided by 35 medical commissions in Kyiv that carried out preventive medical examinations for people working in hazardous and hazardous working conditions during 2009-2013. It was studied the main forms of general diseases taking into account ICD-10 and occupational diseases. Results. The dynamics of the occupational diseases in the enterprises of Kyiv shows that in recent years there was a decrease of occupational diseases which is consistent with the general trend in Ukraine. General diseases were diagnosed in 30.5 % of employees. The analysis of the total morbidity of workers in Kyiv in recent years shows that the cardiovascular diseases (39.6 %) were the most widespread. The prevalence of hypertension was 42.3 %, vegetative-vascular dystonia – 31.4 % and coronary heart disease – 20.8 %. Therefore, in the diagnosis and treatment of hypertension, the modern clinical, laboratory and instrumental methods should be used, according to the unified clinical protocol of primary, emergency and secondary (specialized) medical care, clinical recommendations for arterial hypertension. The chairpersons of medical commissions conducting the periodic medical examinations and determining the proficiency of a worker with hypertension to a profession under the conditions of harmful and dangerous manufacturing factors, must use the criteria of professional suitability in accordance with the order of the Ministry of Health of Ukraine N 246 dated May 21, 2007 “On Approval of the Procedure for Carrying Out the Medical Examinations of Employees of the Certain Categories” and to form groups of dispensary observation. Conclusions. It is necessary to adhere to the sanitary-and-gygienic requirements regulating the permissible level of production norms in the workplace; rational use of remedies of individual and collective protection; to introduce the principles of time protection, the system of the training of the administration, the services of the labor protection on the enterprises on the basis of healthy lifestyle, socio-psychological adaptation, the preservation of health in the workplace, etc. The requirements for further improvement of normative acts on the examination of the proficiency and performance of the certain categories of workers with existing the general and occupational diseases are needed.

50-52

Authors: Yatskevych A.

Introduction. Attention to the problem of Valgus deviation of the first toe (VDFT) does not weaken for about 200 years, due to its considerable population distribution (18,0-20,0%), as well as the lack of treatment efficacy, the recurring nature of deformation Aim. To optimize the treatment of VDFT, improving the methods of osteosynthesis after the corrective osteotomy of the I pectoral bone. Materials and methods. The results of treatment of 42 patients with severe forms of VDFT were analyzed. The average age of patients was 52 years. The clinical, orthopedic, and roentgenologic examination according to standard methods was conducted. The angle of the VDFT was more than 35°, the first inter-axial angle was more than 18°, the first finger was pierced, and in the I-membranous-phalangeal joint – subluxated, the displacement of the lateral sesameiform bone reached 100.0%. All the patients were treated with proximal corrective osteotomy of the I pectoral bone with an osteosynthesis using screw according to the technique we upgraded. Results. Postoperative wounds in all cases were healed by the initial tension. The consolidation of osteotomy based on the results of the X-ray examination took place in the period of five to six weeks. According to the assessment of the AOFAS scale, in three cases (7.1%) satisfactory results were noted. Of these, in one patient (2.4%), although there was a good correction of the shape of the foot, contracture in the I plexus- phalangeal joint arose because of the patient’s late removing of the syringe. In two patients (4.8%) the correction was partially lost (up to 10 °) with a satisfactory foot function and no pain. This correlated with the phenomena of osteoporosis of the bones of the foot in these patients. In 39 operated patients (42.4%) there were good and excellent results. In particular, in 17 patients (40.5%) – the average score was 82.4 and in 22 (52.4%) – 95.7. The results of the treatment were consistent with the results obtained in patients operated with the use of plates with angular stability, which today are considered as “golden standard” of osteosynthesis in foot surgery, but compared with them, the proposed method is less traumatic, technically simpler, significantly lower (on average in 10 times cost of implants. Conclusions. Fixing the fragments of the I pectoral bone after osteotomy due to VDFT with a long screw according to our modified method provided early activation, comfortable treatment and a good cosmetic and functional result. The applied method of fixation is effective, technically simple, minimally invasive, economically viable, and allows to improve the results of treatment of patients with VDFT.

58-60

Authors: Kihichak-Borshchevska A.

Introduction. Modernization of society, rapid and massive urbanization, overburdened societal demands, chronic shortages of time lead to an increase in the impact of stress factors on human health in general and on mental health, in particular. Studies have found that people capable of building close social relationships have less stress-related disorders and higher recovery potential after psychotraumatic situations and illnesses. The study of the illness factors in the relationships can be cunducted in the context of the mental health. Consequently, technology, social mobility, family structure change; prolonging the search period for a partner, increasing the age of marriage, waivers of formal legalization of relationships and procreation, non-prolonged relationships and low satisfaction rates. In addition, the character of interpersonal communication has recently changed: it acquires features of independence, remoteness, isolation, loneliness and loss of intimacy. Aim. To describe the primary models of family relationships as a predictor of mental health. Materials and methods. Content analysis, method of system and comparative analysis, bibliosemantic method of research of actual scientific researches concerning the primary models of family relations as a predictor of mental health were used. Results. The interest of science covers the origins of the relationships based on an attachment as a significant factor. If the patient in a search of support calls to a doctor and, in particular, to psychotherapist, it indicates the existence of a particular causative agent that enabled this man’s attachment system. The theory of attachment reflects only a part of the dynamics of personality formation, namely, one that has a decisive influence on the “building” of the relationships. If a patient in search of support seeks a doctor, and in particular a psychotherapist, this indicates the existence of a particular agent that has activated the attachment system of this person. Therefore, it is clear that the knowledge of various manifestations of such patterns of affection and preconditions for their occurrence is necessary for physicians of all specialties. This will increase the diagnostic care of the doctors to the repertoire of the factors of health and mental health including. With such knowledge it is easier to establish an effective compliance with the patient. At the same time, there is a possibility of fruitful application of the attachment postulates in the prevention of bodily and mental illness. Conclusions. The processing of the mentioned system provides an opportunity for the formation of new accents in psyсhoeducation and setting the effective compliance with the client.