Lviv Clinical Bulletin

14-18

Authors: Yagensky A., Pavelko M., Sichkaruk I.

Introduction. Atrial fibrillation (AF) occurs in 8.0-22.0% of patients with acute myocardial infarction (MI). It is associated with a significant increase in both hospital mortality and mortality over a 5-year observation period. AF can be the result of a number of pathological processes – hemodynamic disorders, ischemia or AF (especially in patients with early AF), right ventricular infarction, pericarditis, excessive release of catecholamines, chronic lung diseases, acute hypoxia, use of sympathomimetics, hypokalemia, etc. Aim. To find out the incidence of AF, its association with structural changes in the heart, heart failure, and other factors in patients in the remote period after MI. Materials and methods. To assess the AF prevalence and its association with the changes in heart structure and heart failure 169 patients with previous MI (135 men, 34 women; mean age 57,3 ± 11,4 years) were included into the study. Mean time after the first MI was 4,96 ± 4,64 years. AF was found in 33 patients (19,5 %): in 23 patients (13,6 %) AF was considered as permanent, in 10 (5,9 %) as paroxysmal. Results. As result of a multiple logistic regression analysis, only the age and the volume of a right atrium were found as the independent predictors of AF. Every 10 years of life of the patients the probability of the permanent AF risk increases more then two-fold (110,0 %), and increase of the volume of right atrium for every 50,0 ml – three-fold (200,0 %). Prevalence of permanent AF increases with the growth of heart failure functional class whereas paroxysmal AF does not depend on heart failure severity. It was found that AF occurs in 19.5% of the patients in the remote period after MI, paroxysmal form – in 5.9%, permanent – in 13.6%. The frequency of continuous permanent AF in patients after MI increases with an increase of the severity of heart failure. At the same time, the functional class of heart failure was not an independent predictor of AF. Patients with permanent AF were older, had larger atrium, more severe heart failure, and greater degree of regurgitation through the mitral and tricuspid valves. Patients with paroxysmal form of arrhythmia occupied an intermediate position among the patients with a permanent form and without arrhythmia for most of the indices. Independent predictors of AF were only the age and volume of the right atrium. Conclusions. When assessing the risk of AF special attention should be paid to the parameters like the size of the right atrium and the degree of regurgitation through the tricuspid valve.

24-29

Authors: Zastavnyy I., Yashchenko A., Lutsyk A.

Introduction. The concept of “miscarriage” (MC) includes involuntary abortion in the period from conception to the 16th-26th week of pregnancy depending on the norms of medical legislation of different country. Approximately 15.0% of pregnancies are interrupted, and mostly (three quarters of cases) in the first trimester. Aim. To investigate lectin-binding carbohydrate determinants of the structural components of the chorionic villi of human embryos, dead as a result of sporadic and habitual non-pregnancy in the first trimester of pregnancy. Materials and methods. Tissue samples of chorionic villi of 8 human embryos, lost due to sporadic and recurrent miscarriages in the first trimester of pregnancy (gestational age 4-13 weeks), were subjected to lectin histochemistry investigation. Group of sporadic miscarriages included 3 specimens, recurrent miscarriages were represented by 5 chorionic villi samples; control group consisted of 5 samples obtained from human embryos after artificial abortions of physiological pregnancies at the respective gestational age. The histological material was fixed in 4,0 % neutral formalin and embedded in paraffin. For the general morphology investigation the 5-7 µm thick sections were stained with haematoxylin and eosin. Carbohydrate determinants of chorionic villi were detected by the lectin-peroxidase technique using 4 lectins, namely, PNA, WGA, GNA and PFA. Results. Microscopic evaluation of histological preparations of chorionic villi of 4-13-week human embryos, artificially or spontaneously eliminated, makes it possible to assess their viability and the ability to perform physiological functions. Lectinogistochemical studies showed a high affinity of PNA, GNA, WGA and PFA lectins with structural components of chorionic villi of 4-13-week human embryos. In the group of the usual miscarriage of pregnancy compared with the group of sporadic miscarriages and the control group of artificially eliminated embryos, the highest level of expression of lectins receptors WGA, GNA and PFA was found. Among the four lectins used, the highest affinity with the components of the villi of human chorionic embryos, especially with syncytiotrophoblast, was revealed by WGA lectin. Lectin PNA did not demonstrate diagnostic value for the detection of these pathological conditions, since its reactivity with the structural elements of the choronic villi of the control and experimental groups was identical. Conclusions. General morphology investigation revealed the alterations of shape and structure of chorionic villi after miscarriages in comparison to the control specimens. There was also detected an increased reactivity of surface and intravillous glycoconjugates with GNA and WGA lectins indicating the enhanced exposure of terminal Man and DGlcNAc / NeuNAc in chorionic villi obtained after miscarriages of both types. The redistribution of the lectin receptors was more obvious in chorionic villi after the recurrent miscarriages compared to the sporadic ones. These observations apparently encompass the alterations of placental barrier due to the increased apoptotic rate as well as certain imbalance in the processing and/or degradation of sialoglycans in chorionic villi.

34-35

Authors: Matoshvili M., Katsitadze A., Kiladze N., Tophuria D.

Introduction. Scleroderma is a chronic disease of unknown aetiology characterized by skin fibrosis and is divided into two clinical entities: localized scleroderma and systemic sclerosis. But the localized scleroderma is not accompanied by Raynaud’s phenomenon, acrosclerosis and internal organ involvement and the life prognosis of patients with localized scleroderma is good. Scleroderma “en coup de sabre” (ECDS) is considered a linear localized form of scleroderma or morphoea. It usually involves, unilaterally, the frontoparietal area, but may extend downwards to the face. Most cases begin before 10 years of age. The aim of our study was to investigate the histological characteristics and their clinical association in ECDS. Materials and methods. The present study was carried out at the Department of Dermatology and Venereology in Tbilisi State Medical University. 11 patients (2 men and 9 women) with lesions clinically and histologically diagnosed as ECDS were retrospectively included. Patients who were treated with immunomodulating agents, including systemic corticosteroids and immunosuppressants before presentation, or patients complicated with Parry – Romberg syndrome were excluded from the study. All patients were subjected to: history taking including: age, sex, duration of the disease, family history; clinical examination; skin biopsy – evaluated for epidermal atrophy, spongiosis, vacuolar degeneration of basal cell layer, satellite cell necrosis, basal pigmentation, melanin incontinence, perivascular infiltrate, perineural infiltrate, periappendageal infiltrate, vacuolar changes of follicular epithelium and dermal fibrosis. Results. All ECDS patients demonstrated epidermal lymphocytic infiltrate, tagging of lymphocytes along the dermo-epidermal junction and vacuolar changes, regardless of disease duration, clinical presentation and the intensity of perivascular lymphocytic infiltrate. Furthermore, when we defined patients with disease duration of < 3 years and of ≥ 6 years, respectively, the degrees of perivascular and/or peri-appendageal infiltrate and vacuolar changes of follicular epithelium were much greater, whereas epidermal atrophy was less frequently seen, in early ECDS patients than in late ECDS patients. The intensity of interface dermatitis in epidermis was comparable between early and late ECDS lesions. Also it’s important to mention, that in our study in early stage localized scleroderma the characteristic histological finding is not only perivascular lymphocytic infiltrate. Vacuolar changes in epidermis is also a common histological feature in the sites of damaged skin of ECDS patients and vacuolar changes in follicular epithelium and peri-appendageal infiltrate serve as a histological marker of early and active ECDS lesions in addition to perivascular infiltrate. Conclusions. Although the pathogenesis of localized scleroderma still remains unknown, the present observation and received results are useful to determine the activity of skin lesions in ECDS and provide us a new clue to further understand the pathogenesis of this disorder.

39-42

Authors: Abrahamovych U.

Introduction. Osteoporosis is a systemic disease of the skeleton characterized by a decrease in bone mass and a violation of the microarchitectonics of bone tissue, which leads to increased bone fragility and fractures. Today, osteoporosis is one of the priority health problems due to the high prevalence and severe complications that cause disability and increased mortality among the population. Epidemiological studies have shown that the distribution of low bone mineral density in patients with systemic lupus erythematosus (CLE) is higher in comparison with the general population. Osteopenia in patients with SLE is found in 25.0-75.0% of the cases, and osteoporosis – in 1.4-68.0 %. In a retrospective population study, 702 patients with SLE have shown that the risk of symptomatic transient events caused by osteoporosis in the experimental group is 5 times higher than the control group of healthy women of the same age. Aim. To find out the features of bone remodeling in patients with SLE, depending on the degree of bone mineral density reduction, based on the study of the biochemical bone markers in blood serum. Materials and methods. 68 patients with SLE with reduced bone mineral density by the ultrasound densitometry were randomized into the study. The average duration of the SLE was 10.19 ± 0.84 years; All the women at the time of the survey were in pre-menopausal status. 100.0 % of the patients received methylprednisolone at a dose of 4.0-32.0 mg/day (mean dose – 12.12 ± 0.91 mg/day) and calcium supplements (daily dose of 1000.0 mg) in combination with vitamin D (daily dose – 400.0 IU). Results. The indicators of bone tissue remodeling (β-crossLaps, P1NP, osteocalcin) in the serum of the patients with SLE are significantly higher in patients with SLE compared to the group of healthy individuals that may be caused by both – disease activity and long-term reception of steroids. In patients with SLE in combination with osteoporosis, according to the results of ultrasound densitometry, there were significantly increased markers of the formation of bone tissue – P1NP and osteocalcin, compared with both physically healthy subjects and patients with SLE who have osteopenia of II and III degrees. β- CrossLaps statistically significantly differed only in the groups of practically healthy persons and those with osteopenia of the II degree, which may be due both to the activity of the disease and the long-term use of glucocorticoids. Сonclusions. In patients with SLE there are bone remodeling features depending on the degree of bone tissue mineral density reduction, namely, – in case of osteoporosis, diagnosed by the ultrasound densitometry, remodeling is caused by the significant disorders of osteoblasts and osteoclasts functions, in case of III degree osteopenia – of osteoblasts function.

49-53

Authors: Shorobura M.

Introduction. Taking care of children with multiple sclerosis (MS) requires coordinated efforts of parents and a multidisciplinary medical team: pediatricians, physiotherapists, psychologists, urologists, nurses. Care should ensure maximum improvement in the quality of life of a small patient, especially during the exacerbation of MS. Aim. To describe the current general principles of treatment of MS in children. Materials and methods. The article describes the main approaches to the use of approved medicines: interferon-β1b, glatiramer acetate, iterferon-β1a s/c, interferon-β1a i/m, mitoxantrone (Cyclophosphamide), Tizabri (natalizumab) in children with multiple sclerosis. Also the results of clinical trials conducted in children with MS are described. Results. Symptoms of the exacerbation of MS can occur and increase from a few days to several weeks, although for very young children, there is a sudden beginning. Emergency medical care is needed for children who have symptoms of relapse of the MS disrupting functions or causing discomfort. The mild symptoms of MS that do not violate the patient’s function do not require medication. Most children are well tolerated with corticosteroids, but minor side effects are possible. Children with frequent recurrence of MS require repeated courses of pulse therapy with methylprednisolone. Such children may experience glucocorticoid complications, including osteoporosis, avascular necrosis, hyperglycemia, obesity, leg swelling, adrenal dysfunction, acne, cognitive impairment, cataract, glaucoma and hypertension. Side effects of glucocorticoid effect should be minimized and not using prolonged scheme (over 21 days) of methylprednisolone. Intravenous immunoglobulin is used as an alternative treatment for the exacerbation of MS in children with frequent relapses, inadequate pulsed therapy with solumederol or its pronounced side effects. As of today, there are six officially approved drugs for the treatment of remitting-recurrent type of MS: three forms of interferon-β (IFN-β) (Rebif®, Avonex, Betaferon®); Glyamerate Acetate (Copakson®-Teva); Mitoxantrone (Mitoxantrone “EBE-BE”) and natalizumab (Tizabri). The pathogenetic treatment should be initiated immediately after the confirmation of the diagnosis of MS, since efficacy is higher in the early stages of the disease. IFN-β and glutamomer acetate are safe, tolerant, and effective, since they reduce the frequency of relapses in the early stages of the disease. Conclusions. Undoubtedly, treating patients with MS, it is very important to act in accordance with the recommendations based on the evidence base, not forgetting the individual approach to patients, taking into account the clinical form and type of progression of the disease.

61-64

Authors: Hanych T.

Introduction. Recently, much attention is paid to comorbidity. It is proved that in patients with bronchial asthma (BA) gastroesophageal reflux occurs significantly more frequently than in general population (70.0–80.0 %), which naturally provokes interest to this consolidation. As early as 1892, W. Osler first described an attack of an aspiration caused by aspiration of gastric contents, initiating the study of reflux induced asthma. Scientists distinguish a number of factors that influence its occurrence: the weakness of the esophageal sphincter, the failure of induced cardia, the keel of the esophagus, the reduction of the resistance of the mucous membrane of the esophagus due to the constant irritation of the reflux, discoordination of the swallow reflex and the closure of the vocal cavity, and also the occurrence of reflux in the bronchial tree. Aim. To describe the contemporary views on the problem of comorbidity of gastroesophagal reflux disease (GERD) and BA. Materials and methods. Content analysis, method of system and comparative analysis, bibliosemantic method of the study of actual scientific research concerning the problem of comorbidity of GERD and BA was used. Results. Lung function testing results analysis performed in our study, showed that patients with both BA and reflux had significantly lower values of volume parameters, whereas velocity parameters did not significantly differ from those without reflux, suggesting more pronounced restrictive lung abnormalities in asthmatic patient with gastroesophageal reflux diseases (GERD). Besides, subjects with asthma and GERD combination were less responsive to bronchodilator therapy and therefore had worse asthma control. Despite the fact that BA combined with GERD has more severe course and poorer response to treatment, the results of study regarding efficacy of anti-reflux therapy were ambiguous. Although after such therapy the majority of patients with erosive form of GERD demonstrated both less severe asthma symptoms and lower demand in controller medications, there was no any improvement in the results of lung function testing. In patients with asymptomatic GERD the treatment had no effect on the clinical presentations and asthma control. Conclusions. There is a need for further study of causation and treatment strategy in patients with a combination of BA and gastroesophageal reflux. After all, timely diagnosis and treatment of erosive forms of GERD in such patients make it possible not only to avoid complications, but also to reduce the manifestations of asthma.

13-16

Authors: Kravchun P.

Introduction. Such diseases as coronary heart disease (CHD) and diabetes mellitus (DM) are common and their prevalence is constantly increasing. The information accumulated in the modern professional literature makes it possible to study the peculiarities of the appearance of systolic and diastolic dysfunction in patients with CHD, especially after the myocardial infarction, due to the appearance of the structural and functional myocardial changes, left ventricular (LV) geometry, and its remodeling, that depends on the presence of risk factors, in particular, type 2 DM. Aim. To evaluate the parameters of the geometry of the left ventricle in patients with post-infarction cardiosclerosis and concomitant type 2 diabetes depending on the systolic function of the LV and functional class of the chronic heart failure. Materials and methods. The study involved 68 patients with post-infarction cardiosclerosis and type 2 diabetes. The comparison group consisted of 80 patients with postinfarction cardiosclerosis and control group – of 35 healthy individuals. Results. Type 2 diabetes is a predictor of the development of concentric hypertrophy of LV in patients with post-infarction cardiosclerosis, which is a reaction of the heart on the prolonged loading and violation of microcirculation in the myocardium, and also leads to a complex structural and functional reorganization of the heart with the emergence of mainly concentric remodeling and concentric hypertrophy of LV with a tendency to reduce the contractile capacity of the myocardium.The increase of the functional class of chronic heart failure in patients with post-infarction cardiosclerosis was associated with progression of LV hypertrophy, decreased inotropic function of the myocardium, increased size and volume of LV cavity, deterioration of the functional status, which is undoubtedly a consequence of the underlying disease and type 2 diabetes. This suggests that the mechanisms underlying the disease are associated with glucose and insulin metabolism disorders, which leads to remodeling of LV in patients with post-infarction cardiosclerosis and type 2 diabetes. Conclusions. Type 2 diabetes is a potentiator of LV myocardial remodeling in patients with systolic dysfunction, which originated on the basis of postinfarction cardiosclerosis. Comorbidity of post-infarction cardiosclerosis and type 2 diabetes leads to an increase in the severity of post-infarction remodeling associated with an increase in the functional class of chronic heart failure.

21-26

Authors: Abrahamovych U.

Introduction. According to the information from literary sources, in 12.0-49.0 % of the patients with systemic lupus erythematosus (SLE) there is arterial hypertension (AH). According to the Framingham study, increased blood pressure (BP) leads to an increase in cardiovascular morbidity by 4-5 times compared with the general population, and the risk of cardiovascular complications in patients with SLE is 50 times greater than that of those who do not have SLE. Aim. To find out the features of the blood pressure daily monitoring (BPDM) in patients with SLE with varying degrees of activity of the pathological process. Materials and methods. The survey includes 83 people (71 women (85.5%) and 12 men (14.5%)) aged from 17 to 68 years old (at the time of BPDM average age – 38.6 ± 1.3 ). All the patients have been diagnosed with SLE according to the criteria of the American College of Rheumatologists (1982, 1997) and have elevated BP, – the experimental group. These individuals 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 BPDM. Results. It was found, that in patients with SLE of the 1st activity degree the levels of mean heart rate (HR) during the day, active and passive periods and diastolic blood pressure (DiaBP) time index (TI) during the passive period were significantly elevated; other significant deviations of BPDM parameters weren’t recorded. In the patients with the 2nd degree of SLE activity the significantly elevated levels of mean HR during the day, active and passive periods, systolic blood pressure (SysBP) daily index (DI), DiaBP and mean BP (MBP), SysBP TI, DiaBP TI and MBP TI during the day and the passive period, SysBP TI during the active period were found. In the patients with SLE of the 3rd activity degree were recorded the significantly elevated levels of mean HR during the day, the active and passive periods; average daily levels of SysBP, DiaBP and MBP throughout the day, the active and passive periods; SysBP DI, DiaBP DI and MBP DI; SysBP TI, DiaBP TI, MBP TI throughout the day and active and passive periods. Conclusions. The detected regularities of BPDM help to optimize the treatment of arterial hypertension in patients with SLE.

32-34

Authors: Kiladze N., Shulaia T., Bulinska A., Abrahamovych L.

Introduction. Basal cell carcinoma is one of the most common malignant tumors, which accounts for about 75.0 % of all skin cancers. Despite the fact that the characteristic manifestations of BCC are fairly typical, different clinical sub-varieties can vary greatly and require extended differential diagnosis. The aim of the present study – definition and detalization of dermatoscopic criteria for non-pigmented basal cell carcinoma of the skin. Materials and methods. During the three years study were revealed 75 cases of non-pigmented basal cell carcinoma in 58 men and 17 women aged from 47 to 80 years (mean age – 62 years). All patients were with I–II type of skin photosensitivity in accordance to Fitzpatrick. The diagnosis was exhibited on the basis of clinical, dermatoscopic picture and further cytological or histological studies. Dermatoscopic images were received due to DermLite 3 GEN DL3 connected to Samsung Galaxy (Android) smartphone. The evaluation of dermatoscopic picture of different types of BCC was done in accordance with H. Kittler pattern analysis algorithm. Results. In patients with light skin types the non- pigmented forms of basal cell carcinoma are dominant; such forms are often described as pink pearl nodes or sites of erythema with desquamation and ulceration located mainly on the open photo exposed areas. In such cases the clinical diagnosis is often uncertain or implicates a variety of differential diagnoses. In this context, dermoscopic features may be of primary importance. The main dermatoscopic criteria for the diagnosis of non-pigmented BCC is the pattern of blood vessels according to the existing literature. A further important hint in the diagnosis might be found in the presence of small ulcerations, which appear on dermoscopy as red to yellow or skin colored structureless area. The most consistent global pattern of vessels in all categories of non-pigmented BCCs was mono- or polymorphic pattern of vessels, which in the majority of cases was represented by serpentine and coiled vessels with branchy arrangement. Such a picture was observed in 92.0 % of our cases. Other additional features were structureless area often with adherent fibers and randomly spaced white lines. Our findings, regarding vessels are in accordance with the currently available literature; some minor differences concerning the rates of vessels morphology are due to the lack of metaphoric terminology which is the main methodological disadvantage of dermatoscopy. It proves once again that in this situation an affordable and logical method based on the analysis of the pattern is urgently needed. Сonclusions. Presented by H. Kittler algorithmic method based on pattern analysis gives the possibility to establish the specific dermatoscopic criteria which are essential for early and accurate diagnosis of different BCC subtypes. Further studies are needed to evaluate the specificity and sensitivity of these dermatoscopic features.

39-44

Authors: Volnytska H., Ilnytskyj I., Kostyk O., Bilozir L.

Introduction. Bronchial obstruction that persists in patients after primary treatment of tuberculosis or pneumonia is an important immunodependent link for their pathogenesis, defining the main manifestations of the disease, the rate of increase of the severity and probability of various complications, can be a major clinical syndrome of both chronic obstructive pulmonary disease (COPD) and bronchial asthma (BA), which greatly complicates the diagnostic process and the appointment of an adequate treatment. The clinical signs of the course of COPD and BA, including after the completion of the main course of treatment for tuberculosis or pneumonia, are largely influenced by bronchoobstructive syndrome (BOS) – an important immune-dependent linkage of their pathogenesis, which determines the main manifestations of the disease, the rate of increase in its severity and the probability of occurrence of various complications. Aim. To find out the diagnostic value of the parameters characterizing the state of the immune system in patients with COPD and asthma with BOS, after the completion of the main course of treatment for tuberculosis or pneumonia. Materials and methods. To study the immunological criteria for verification of the COPD and asthma with bronchial obstructive syndrome (BOS) in patients, who took tuberculosis or pneumonia treatment, were examined 129 (100 %) patients with uncomplicated TB without destructive changes in the lungs (first or third clinical category of registered patients) and community acquired pneumonia with BOS who were treated at the therapeutic and pulmonology departments of the Lviv Regional Pulmonology Center. Results. The changes found in the subpopulation lymphocytes in the peripheral blood in patients with COPD and asthma indicate more expressed manifestations of depression in the immunity of T-area in patients with COPD, which is a consequence of more severe inflammation in patients with COPD than in ones with asthma. The quantitative deficiency of T lymphocytes in patients was also established and accompanied by the inhibition of their proliferative activity, and in patients with COPD, this inhibition was more pronounced. The activation of B-system of immunity in patients with COPD compared with patients with asthma, was characterized by a more pronounced increase in the relative number of B-lymphocytes, increased levels of circulated immune complexes (CIC) and dysimmune globulinemia, manifested in an increased level of Ig G, Ig A in patients with the COPD and growth of Ig E in patients with asthma. Conclusions. These research findings have made it possible to affirm that of the diagnostic value for verification of the COPD in tuberculosis or pneumonia patients with BOS were indicators of blast transfection reaction of lymphocytes with phytohemagglutinin, CD3+-, CD4+-, CD4+/CD8+-, CD16+-lymphocytes, CIC, Ig G, and for the verification of BA – indicators of CD22+-lymphocytes, CIC, Ig E.

48-51

Authors: Kitsera Al.

Introduction. Noise in the ears (NE, tinnitus) means pathological hearing impairments or sound phenomena that occur in the ear or in the head and is one of the most common symptoms of a variety of pathological conditions. The problem of the tinnitus is not fully understood, as it can be associated with a large number of factors that affect not only the organ of hearing but also other systems and organs. NE, according to various data, have 15.0-40.0% of the population, 25.0% of those with an NE, it complained the life and professional activity, and even causes self-isolation. Therefore, in many countries there are magazines devoted to the issue of ear noises, societies of patients with NE are created, specialized clinics work. Aim. Determine the etiologic, pathogenetic and clinical aspects of patients with the main complaint about the HS and the rational principles of diagnosis and treatment of pathological conditions accompanied by HS. Materials and methods. On the basis of the auditologic laboratory of the Otorhinolaryngology clinic and the Otorhinolaryngology polyclinic department of the Lviv Regional Clinical Hospital during 2008-2013, an expanded inspection of patients who were consulted on the problem of HS as the main or single complaint was conducted. Information was taken from patients with noises in the ears or in the head that lasted for more than a month (452 ​​cases). Among the patients, there were 231 men and 221 women, so, there was no reliable dependence of the incidence of NE on the gender. The age of the patients varied from 15 to 83 years, the average value was 46.9 years, most often were persons aged 40-59 years (226 – 50.0%). 168 patients were rural residents, 284 – lived in cities. Results. NE is one of the symptoms, sometimes the only one of the diseases of the middle and inner ears, the vessels of the brain or the central nervous system (CNS). In the majority of patients with NE, sensory or combined increase of hearing thresholds of insignificant degree is noted, more pronounced at high frequencies. The increase in hearing thresholds was most pronounced at frequencies that corresponded to the audiologic characteristics obtained with the help of tannithometry, which mainly showed high-frequency NE. Changes in short-wave auditory actuation potentials were most pronounced as a result of testing by tone signals that corresponded to the frequency of NE. Integrated etiopathogenetic treatment was effective in all the patients with NE. Conclusions. A comprehensive audiologic examination in the case of an NE is appropriate for the purpose of choosing a rational treatment. The method of non-medicated sedation by phototyping is quite effective in most patients, which gives grounds to consider its further promising development.

57-62

Authors: Demydova A.

Introduction. The prevalence of H. pylori infection has declined in recent years. However, the processes of population migration offset this difference, and the decline in the rate of distribution of H. pylori has recently slowed down. In addition, the frequency of unsuccessful eradication has sharply increased in many countries due to the resistance to antibiotics. In Ukraine, according to the Center of Medical Statistics of Ukraine, the incidence of peptic ulcer over the same period has increased by 38.4% and has no tendency to decrease, and the prevalence of the duodenal peptic ulcer has reached 150 cases per 100 thousand population. Even the intensive introduction of new treatment programs, despite their benefits, does not significantly change the general rates of morbidity and hospitalization of this patient’s contention. Aim. To find out the effectiveness of treatment of the patients with duodenal peptic ulcer and the need for their retreatment since the introduction of the Maastricht Consensus. Materials and methods. A retrospective analysis of the efficacy of treatment of the duodenal ulcer of the patients (age – 17-72 years, average age 43.9 ± 1.3 years, 2 191 (63.60%) men and 1 255 (36.40%) women), has been carried out over the 10 years since the introduction of the Maastricht Consensus provisions into the clinical practice. Results. It was showed that the re-hospitalisation frequency among the patients with duodenal peptic ulcer did not change. The frequency of repeated referrals due to the unsuccessful eradication in this category of patients increased significantly (20.72 % in 1996 vs. 38.82 % in 2006; p < 0.01) as well as the percentage of the reinfected patients (5.80 % in 1996 vs. 24.71 % in 2006). An analysis of the age composition of patients showed that the percentage of reinfecting in individuals aged 60 and over was recorded in 11.50% of cases, at the age of 20-59 (the most able-bodied age) 16.20% of the patients were reinfected. The smallest number of reinfected was recorded in the group of the patients under the age of 19 (5.62%). No difference was noticed in gender composition between the reinfected patients and the patients who requested the treatment repeately after the unsuccessful eradication. In the most working capable part of Lviv region population every third patient with duodenal peptic ulcer requested the repeated treatment during a year. Conclusions The prevalence among the patients of working age of the duodenal peptic ulcer and the resistance of the helicobacteric infection to antibacterial agents requires a comprehensive study and the adoption of appropriate management decisions in various spheres of life.

14-17

Authors: Markin L., Shatylovytch K.

Introduction. The pathological changes of the venous system in pregnant women and the mothers are manifested in the occurrence of varicose veins of the lower extremities, venous thrombosis and thromboembolism. Varicose veins of the lower extremities are observed in 20.0-40.0% of pregnant women, in more than 70.0 % of women, manifestation of this disease occurs in the third trimester of the gestational process. The structural changes and a further decrease in the elasticity of the walls of the venous vessels are systemic, but the most affected are the veins that are least covered by muscles – the surface veins of the lower limbs, rectum, small pelvis, and also the fetoplacental complex. Actually, one of the gestating complications of chronic venous insufficiency is the formation of secondary placental dysfunction with clinical implementation in the form of fetal distress, fetal growth retardation syndrome (FGRS), preeclampsia (PE). Aim. To evaluate the effectiveness of the treatment of varicose veins of the lower extremities and prevention of its gestational complications using venotonic drug Normoven. Materials and methods. There were examined 60 women aged 21-45 (gestational age 28 weeks or more) who suffered from the varicose veins of the lower extremities. In all patients, the severity of the disease corresponded to the clinical class C1-C3 according to the international classification (CEAР). Observations included the all standard clinical and laboratory examination, antenatal cardiotocography (after 30 weeks), determination of fetal biophysical profile (BPP), and ultrasound doplerometric examination determining the state of blood flow in the arteries of the uterus, placental bed (spiral artery (SA)), umbilical (UA) and middle cerebral artery (MCA), renal artery (RA), venous duct (VD)). The effectiveness of the proposed treatment was evaluated by measuring the diameter of the lower leg at the ankles once a week and subjectively. Were evaluated the following symptoms: pain and feeling of heaviness in the lower extremities at the end of the day, reduced tolerance to static loads, and the presence of a vessel in the fluid muscle. Results. The first, yet preclinical, response of the mother-placenta-fetal system to any disease of the maternal organism is the violation of hemodynamics in its utero-placental contour. It was found that the progress of the gestational process in pregnant women with the varicose veins of the lower extremities in 6.7% was complicated by fetal distress, 13.3% – FGRS, 36.7% – PE. In view of the pathogenetic commonality of the varicose veins of the lower extremities and PE as the realization of endothelial dysfunction, intravenous systemic measures can be considered as one of the measures to prevent the onset of gestation in the second half of pregnancy in such patients. Thus, 23 pregnant women (76.7%) after the treatment using Normoven noted no leg pain at the end of the day and after walking or prolonged standing. The reduction of the pain syndrome to “slight discomfort” was in 12 (40.0%) patients. In 7 out of 23 pregnant females, edema of the legs and trunk disappeared, due to the improvement of microcirculation, lymph drainage and the elimination of tissue hypoxia as a result of the combined administration of diosmin and hesperidine. The average diameter of the legs in this subgroup was 24.5 ± 2.8 cm. Comprehensive treatment interrupted the progression of the varicose process, shin-like protrusions did not look over the surface of the legs Conclusions. The efficacy of the venotonic drug of systemic action Normoven in the treatment of varicose veins disease and positive effect on the intensity of the uterine–placental blood flow have been established. The possibility of applying of Normoven in preventing the development of preeclampsia in pregnant women with varicose veins of the lower extremities has been proved.

23-34

Authors: Abrahamovych L., Abrahamovych-Stasenko O.

Introduction. In all countries of the world, in particular in Ukraine, there is a significant increase in the incidence rate of the tumors of the skin, the prevention and treatment of which has a significant medical, social and economic significance. In clinical practice, different methods of treatment of benign and malignant neoplasms of the skin are used, among which surgical method, laser and electrocoagulation, cryodestruction using liquid nitrogen, ointment based on concentrated alkali and acids, etc., have been widely used. The statistical indicators of evaluating their efficacy indicate that good, long-term results of the treatment of malignant neoplasms of the skin are achieved only in 15.0-25.0% of patients. The search for new, more effective methods of treating this category of patients deserves special attention. The aim of this work is to find out the effectiveness of the treatment with herbal liniment “Antineoderm C-A” in patients with benign and malignant neoplasms of the skin. Material and methods. For 28 years we have examined and cured 20221 patients with different benign and malignant neoplasms (8 214 (40.62%) men, 12007 (59.38%) of women), aged 3 to 93 years. Of these, 329 (1.63%) patients with early melanoma and 118 (0.58%) patients with squamous cell carcinoma of the skin, which until now have not been treated, 1024 (5.06%) patients with a diagnosis of “basal cell carcinoma of the skin” , In which there was a relapse of the disease after the traditional methods of “removal” in other clinics. Of the 16335 patients (80.78%) with benign neoplasms, 7350 (45.00%) were not helped by other methods of treatment. The following survey methods have been used: visual inspection with dandruff, dermatoscopy, biopsy in cases of benign tumors of the skin (to clarify the diagnosis) with subsequent histological and pathomorphological studies of biopsy. In patients with early stages of melanoma (a biopsy is categorically banned because it can lead to traumatic metastasis of the tumor), a specific oncologic marker, S-100 melanoma protein, has been identified that can detect the presence of metastases. For the patients with melanomas in the early stages it was performed a comprehensive clinical-laboratory and instrumental examination of the internal organs for detecting the presence of metastases in accordance with approved protocols of the Ministry of Public Health of Ukraine. Results. In the vast majority of the treated patients there were no unsatisfactory direct results of supervision. The treatment proceeded without complications, except for the patients with plantar warts, which failed to complete the curia because of their refusal from the necessary in this case numerous medical sessions. Among 2349 (100.00%) of patients with different types of warts in 2344 (99.78%) the treatment was good, and unsatisfactory result was observed in 5 (0.22%) patients with plantar warts due to reluctance to continue treatment. And the among the total number of treated patients (20221-100.00%) poor results were observed in 0.02% of patients. Patients with good results of treatment include those 1024 patients with basal cell carcinoma of the skin and 7350 patients with benign neoplasms, who had signs of relapse after applying other methods (surgical, laser and electrocoagulation, cryodestruction using liquid nitrogen, using an ointment based on concentrated alkalis and acids, etc.). Conclusions. Treatment of benign and malignant tumors and melanoma in early stages using “Antyneoderm C-A” is safe and effective, and therefore, regardless of gender and age can be recommended for use in dermatooncology.

39-41

Authors: Markin L., Kunynets H.

Introduction. The presence in the history of two spontaneous miscarriages and more in the first trimester is treated as the usual miscarriage of pregnancy. Endocrine factors, genital infections, extragenital diseases play a significant role in the etiology of habitual miscarriage of pregnancy. It is noteworthy that the frequency of idiopathic (unclear etiology) of the usual miscarriage of pregnancy reaches 50.0-75.0%. Aim. To evaluate the effectiveness of preventive measures with the use of “Pregnaca” by people with idiopathic habitual miscarriage of pregnancy. Materials and methods. The group of observation was 50 women with idiopathic habitual miscarriage of pregnancy, who had been prevented from involuntary miscarriage from a 7-8 week pregnancy. The pregnant first subgroup (25 women) prescribed dydrogesteron (10.0 mg twice daily), the second (25 women) diddgesterone and “Pregnachea” (1 capsule a day). The peculiarities of the course of the gestation process were judged on the basis of the results of ultrasound biometrics, the determination of the internal diameter of the fetal egg and the caudal-parietal size of the fetus. The results of the measurements were compared with the indicators of T. V. Khodareva, A. M. Stigar (1989), obtained during the dynamic monitoring of pregnancy with normal course. With the help of silicicular echography, the degree of myometrium hypertonum, the ratio of the length of the uterus cavity to its anterior posterior size, and the ratio of the length of the cervix to its diameter at the level of the inner eye were determined. Results and discussion. All women in the surveillance group during the previous abortion failed to demonstrate the role of endocrine and immunologic factors, genital infections, chromosomal disorders, extragenital diseases, isthmic-cervical insufficiency. In the 7-8-week period of pregnancy signs of hypertonic myometrium were absent. Local thickening of myometrium during ultrasound examination was not detected. The ratio of the length of the uterine cavity to its forebrain size was 1.32 ± 0.03, and the ratio of the length of the cervix to its diameter at the inner eye level was 1.56 ± 0.04. Clinical signs of the threat of involuntary abortion were not observed. The dimensions of the uterus and the biometric indices of the fetal egg and fetus corresponded to the period of gestation. In the course of the uncomplicated pregnancy, the growth rate of the fetal egg was an average of 0.63 cm, and an increase in the caudal-parietal size of the fetus – 0.84 cm per week. Preventive measures were ineffective in 32.0% of the first subgroup of pregnant women and in 24.0% of women from the second subgroup. In the case of an involuntary miscarriage, the study of fetal heart rate revealed bradycardia (103.7 ± 5.8 beats/min). There was a lag behind the size of the internal diameter of the fetal egg and the coccyx-parietal fetal size for 7-9 days from the date of gestation. The hypertonic myometrium of II-III degree was characterized predominantly. The ultrasound examination then showed several thickening of the myometrium, including in the placental area, which caused a decrease in the anterior-posterior size of the uterus. The ratio of the length of the uterus to its anterior posterior size was 1.70 ± 0.05 (p <0.05). Increasing the activity of the uterus led to a shortening and opening of the cervix. The ratio of the length of the cervix to its diameter at the internal eye level was reduced to 1.20 ± 0.04 (p<0.05). Сonclusions. It was proved that using Pregnacare increases the effectiveness of the preventive measures in case of the idiopathic habitual miscarriage to 25.0 %.

46-49

Authors: Nyankovskyy S., Ivakhnenko O., Iatsula M.

Introduction. Today, despite the already significant experience of implementation of the main provisions of the Bologna Declaration in the domestic educational space, many students and faculty of higher educational institutions (universities) quite often express themselves quite ambiguously, due to the lack of integrity, completeness, thoughtfulness and proper resource provision. It is difficult to expect a brilliant final result if you introduce something in parts. This approach often leads to a negative or distorted result. Aim. To discuss the issues of the implementation of the Bologna process into the medical education of Ukraine. Materials and methods. In this article the debatable questions about the Bologna process implementation into the Ukrainian medical education are studied including thequestions about the students and teachers mobility, teaching load standards, students’ knowledge evaluation system, peculiarities of students’ training in clinical departments. Our own experience of the Bologna Declaration statements implementation into the pedagogical activities of pediatric department of Lviv National Medical University is described. Results. The Bologna process in Ukraine has dramatically increased the time, duration and frequency of formal control of students’ knowledge and skills. And if the number of students in the group who came to the clinic reaches 13-15 people, then the teacher turns into a machine for formal assessment of students’ knowledge. The reduction of classroom hours and an increase in self-learning are often interpreted by the students as a way to get rid of the latter. Practice shows that students themselves learn not only through laziness, but also through inability. This form of work requires a significant increase in the library stock, modern literature, mass free Internet access, virtual educational programs, telemedicine resources, distance learning. Conclusions. To optimize the educational process in Ukraine, the pedagogical load of the teaching staff and the number of students in the academic staff should be fixed as soon as possible. There must be created the modern university clinics with proper funding, students and teachers have to focus on the training of a wiser physician who needs the health care system most, and to improve the equipment of the departments of higher educational institutions and postgraduate education institutions with modern diagnostic and therapeutic equipment and materials, to motivate students to study.

54-57

Authors: Yuzych І.

Introduction. Dilated Cardiomyopathy (DCM) is a chronic disease caused by various conditions which lead to the ventricular dilatation, which decreases their contractile ability of the myocardium. DCM occurs more frequently in men than in women, and is the most common in the age 20-60 years. About one in three cases of congestive heart failure is due to the dilated cardiomyopathy. Symptoms of DCM can occur at any age and may include shortness of breath, swelling of the lower extremities and feeling of fatigue. This article contains a literature review concerning this disease. Aim. To make an overview of modern literature on the issue of DCM. Materials and methods. The content analysis, method of system and comparative analysis, the bibliosemantic method of studying the actual research in relation to the problem of DCM was used. Results. Clinical feature of DCM – increasing heart failure severity refractory to the treatment. In the early stages of the disease, the clinical symptoms are quite small. Patients can only complain of weakness and moderate shortness of breath but do not attach importance to this. Laboratory indices in patients with DCM generally are not informative. Echocardiography, which today is the most important method of the diagnosis of DCM helps to see the increasing of the heart chambers sizes, namely the increase of the end-diastolic sizes of the left and right ventricules, diffuse nature of the lesions, reducing of its contractility and in accordance with this the ejection fraction decreasing, relative mitral and tricuspid valves insufficiency signs. In this case the hypertrophy of the left ventricle walls may be missing, or its size is not commensurate with the sizes of dilatation. With the decrease of the contractile ability of the myocardium the likelihood of detecting the mural clots in heart chambers increases, and this can then become a source of thromboembolism. Regardless of etiology, the treatment of DCM is symptomatic and is based on the correction and prevention of the major clinical manifestations and complications – congestive heart failure, rhythm disorders and thromboembolism. Surgical treatment of DCM is used in case of the resistancy to intensive medical treatment of heart failure and provides heart transplantation followed by immunosuppressive treatment. If there is a risk of the patient’s life-threatening arrhythmia, it is advisable cardioverter defibrillator implantation. Conclusions. DCM is determined predominantly by the degree of congestive heart failure, the risk of sudden death increases with its increase. The main causes of death of patients are ventricular fibrillation, decompensation of congestive heart failure, thromboembolism. The diagnosis of the disease in the early stages allows the appointment of appropriate treatment, and, therefore, preventing the occurrence of fatal complications.

12-16

Authors: Radchenko O., Pylypiv L.

Introduction. Arterial hypertension (AH) is one of the most urgent medical and social problems of the present time due to the considerable prevalence, high risk of complications, and lack of treatment efficacy. Assessing the status of the autonomic nervous system (ANS) is one of the perspectives for the further study and understanding of the disease, which is due to the active participation of the ANS in the processes of adaptation and pathogenesis of a large number of lesions. Vegetative dysfunctions are considered to be a key in the emergence of neurocirculatory dystonia, heart rate abnormalities and cardiac rhythm disorders, myocardial ischemia, hypertensive crises, and increased activity of the sympathetic part of the ANS for a long time is investigated in the course of the onset and progression of AH, including drug-resistant coronary heart disease, congestive heart failure, and metabolic syndrome. Aim. To determine the tone of the ANS and describe the features of the AH course depending on the vegetative status. Materials and methods. 70 patients with AH aged 33 to 81 years (mean age 61.1 ± 1.4 years) were examined, including 47 women (67.1%) and 23 men (32.9%). The average duration of AH was 9.6 ± 0.7 years. In addition to the standard laboratory and instrumental examination, the status of the ANS was assessed by the S. M. Pukhlik questionnaire (1998). The control group included 18 healthy volunteers with an average age of 33.4 ± 3.3 years. Results. It has been found out that 81.4 % of patients with hypertension have sympathicotonia accompanied with higher indices of the systolic and diastolic blood pressure, cardiac rate, more often abdominal obesity (especially obesity classes II and III) as well as hyperlipidemia which conversely are additional risk factors for cardiovascular complications and potential indicators for further prognosis. So, the use of non-medicated (body weight normalization, physical activity, stress reduction) methods and medications (β-blockers, α1-adrenergic blockers, imidazolin receptor blockers, β-stabilizers, sedative preparations) to provide a positive balanceof the ANS should be the subject of further research to normalize blood pressure and reducing the risk of cardiovascular complications. Conclusions. Increasing the sympathetic tone in patients with AH leads to an increase in cardiovascular risk, which should be taken into account when assessing the total cardiovascular risk, identifying a program of treatment and prevention.

23-26

Authors: Tomashevskiy Ya., Vendzylovych Yu., Tomashevska N., Hrupovych L., Danylevych N., Hrupovych M., Sulyga I., Firchuk M.

Introduction. Considering the urgent need to optimize the methods for preventing diabetes mellitus, it is important to find the methods of early diagnosis of carbohydrate metabolism disorders that precede the manifestation of type 2 diabetes mellitus and to promote the method of self-monitoring of carbohydrate metabolism available in Ukraine and abroad for each family. In connection with the peculiarities of energy metabolism, the expediency of studying the pyruvate dehydrogenase activity of blood for the purpose of early diagnosis of diabetes mellitus is obvious. Aim. To identify the persons with a hereditary predisposition to type 2 diabetes mellitus (with mitochondrial diabetes) in the population of the Prykarpattya region using the assessment of carbohydrate metabolism. To recommend the use of a bloodless visual method of studying the total content of α-ketoacids in the urine. Materials and methods. Into the study there were involved 292 practically healthy residents of the Prykarpattya region (166 men and 126 women aged 6 to 80 years) in which the blood glucose level did not exceed 5.6 mmol (100.8 mg%). The state of carbohydrate metabolism was evaluated using pyruvate dehydrogenase and α-ketoglutarate dehydrogenase tests. The monitoring was performed by indicators of pyruvate dehydrogenase activity in blood of healthy persons in the range of 8.01-16.30 μcat/l, as well as the 2-hour α-ketoneuria (6.4-11.4 mg, p <0,01), which was accepted as normal. Results Hereditary predisposition to type 2 diabetes mellitus (mitochondrial diabetes) was detected in 40.76% of the subjects. Of these, 7.88% is due to pyruvate dehydrogenase deficiency and 32.88% of α-ketoglutarate dehydrogenase deficiency. It let us determine a genetic predisposition to type 2 diabetes mellitus (mitochondrial diabetes) in 40.76 % of the patients, in particular, in 7.88 % – due to pyruvate dehydrogenase deficiency and in 32.88 % – due to α-ketoglutarate dehydrogenase deficiency. Conclusions. So, it is recommended to use at home a bloodless visual research method of α-keto acids total amount detection in the urine available to every family, as an effective way of self-control of carbohydrate metabolism, which will facilitate the identification of the individuals with inherited predisposition to the disorders of carbohydrate metabolism (mitochondrial diabetes), followed by the manifestation of type 2 diabetes mellitus and will allow to take the necessary measures to prevent its occurrence.

31-35

Authors: Barna O., Getman O., Korost Ya.

Introduction. Aging is a general property of all living and non-living systems, which represents the accumulation of violations of the structure and reduction of the function of the system. These changes develop over time. One of the important reasons for the aging of a living system is the inadequacy of its renewal. Theoretically, two main mechanisms of aging are distinguished. The first is the genetically determined non-renewal of a number of structures, which with age are gradually destroyed or lose their ability to function. This process is random, it is called stochastic aging. The second mechanism of aging develops due to a decrease in the rate of self-renewal. It is caused by the changes in the effect of programs regulating processes in a living organism and is called regulatory aging. In modern conditions, there is the possibility of using various diagnostic techniques to determine the individual aging profile of an organism and to select on the basis of the obtained results an aging prevention program. Aim. To make an overview of contemporary literature on the issue of anti-aging medicine, its main principles and tasks. Materials and methods. The content analysis, the method of system and comparative analysis, the bibliosemantic method of studying the current scientific research on the issue of anti-aging medicine, its main principles and tasks were used. Results. The emergence of anti-aging medicine is associated with an increase of life expectancy in economically developed countries. People live longer and, for understandable reasons, tend to be active even at a respectable age. The methods of laboratory and functional diagnostics have already reached the level when it is possible to speak about the possibility of accurately predicting the state of health of each person in old age. Prediction algorithm of aging includes an assessment of anamnestic data, physical examination, diagnosis of menopause, assessment of the functional state of various organs and systems using the methods of functional diagnostics, laboratory tests, evaluation of hormonal functions, immunological studies. Conclusions. Anti-aging medicine, its main principles are based on the application of advanced scientific and medical technologies for the early detection, prevention, treatment and reduction of the number of age-related diseases. The slowing down of aging processes aims not only to increase the number of years spent, but also to improve the quality of life in old age.

39-42

Authors: Grishchenko O., Lakhno I.

Introduction. Uterine bleeding in gynecological practice is a vast group of nosological forms, accompanied by increased blood loss during menstruation or acyclic metrorrhagia. Quite often, bleeding is not associated with the presence of structural-anatomical changes in the organs of the reproductive system. At the basis of the dysfunctional uterine bleeding (DUB) is the imbalance of regulatory mechanisms of the hypothalamic-pituitary-ovarian axis. Application of the empirical approach in their treatment from the standpoint of: “Endocrine disorders require hormonal therapy”, – not always, nevertheless, achieves the desired goal. Aim. To study the effectiveness of the drug Tranexam (Nizhpharm, Russia) in patients with uterine myoma and DUB. Materials and methods. We examined 138 patients of the reproductive age. The I group includes 24 practically healthy women. In the II group there were 58 patients with menstrual bleeding, 28 of them were diagnosed with DUB (IIA subgroup) and 30 had small uterine myoma (IIB subgroup). In group III, 56 subjects were monitored. In the III A subgroup there were 26 women with DUB, in IIIB – 30 patients with small fibroids. The diagnosis of menorrhagia was established on the basis of the following criteria: the use of more than 20 pads or tampons per cycle, the need to replace hygiene products during the night, the presence of clots in menstrual blood more than 1.0 cm in size, the duration of bleeding is 7 days or more. Patients of group II received oral contraceptives with 30.0 μg ethinylestradiol according to the contraceptive scheme once a day, and in the bleeding period 1 tablet twice a day. In group III, Ttanexam (in tablets of 250.0 mg) was administered 1.0 g four times a day to patients with menorrhagia. Patient monitoring was performed over three menstrual cycles. In addition to general clinical examination, all 138 patients underwent ultrasound examination of pelvic organs and mammary glands, colposcopy, oncocytology. Patients were consulted by a therapist, an endocrinologist and, if necessary, a hematologist. The effectiveness of the treatment was determined based on the number of hygiene products used, the duration of menstrual bleeding, and the hemoglobin (Hb) level in the blood. The level of adverse reactions under the influence of the treatment with oral contraceptives and tranexamic acid was recorded. Results. No pronounced deviations of endocrinological status have been detected in these patients. It was found out that in women with uterine bleeding the application of the combined oral contraceptives was accompanied by higher rates of side effects such as headache, breast tenderness, nausea and vomiting compared with the application of tranexamic acid. The prescription of tranexamic acid («Tranexam») in pills in patients with menorragia had higher effectiveness than the combined oral contraceptives that was reflected in a significant decrease in a number of required sanitary facilities, duration of menstrual bleeding and a higher level of hemoglobin. The application of tranexamic acid in pills provides the confidentiality of use that increases compliance of therapy and patients’ adherence to treatment. Conclusions. The administration of tranexamic acid (Tranexam) in tablets for the patients with menorrhagia surpassed the effectiveness of combined oral contraceptives, and therefore is recommended for use in such patients in routine practice.

52-55

Authors: Sklyarov E., Maksymets T.

Introduction. Ischemic heart disease takes a leading place in morbidity and mortality structure among the Ukrainians and in the world. There are certain peculiarities of the onset, course and prognosis of the ischemic heart disease in women. For example, in women, there is a later age of coronary artery disease. At the same time, the prevalence of coronary heart disease in women with coronary heart disease is worse than in men. Infant mortality rates in the female population are 19.0%, whereas in males – 12.0%. Mortality among women in the first year after the myocardial infarction reaches 36.0%, which is 10.0% higher than in men. Aim. To make an overview of modern literature on the risk factors and predictors of coronary heart disease in women. Materials and methods. The content analysis, method of system and comparative analysis, the bibliosemantic method of study of the actual scientific researches concerning risk factors and predictors of coronary artery disease in women have been used. Results. Traditional risk factors for coronary heart disease include burdened hereditary history, age, dyslipidemia, arterial hypertension, diabetes mellitus, metabolic syndrome, abdominal obesity, smoking, hypodynamia, inappropriate nutrition, hypoestrogenemia. The following new risk factors have been identified: C-reactive protein, homocysteine, lipoprotein (a), microalbuminuria, uric acid, leptin, adiponectin, fibrinogen, tumor necrosis factor, interleukin-6, gamma-glutamyltranspeptidase, non-alcoholic fatty liver disease, subclinical atherosclerosis. The presence of early coronary artery disease in close relatives of women under 65, men up to 55 years of age is an independent risk factor, although its significance is lower than that of men. An early myocardial infarction in one of the parents increases the risk of coronary heart disease in women by 2.8 times. It is traditionally believed that the risk factor of corobary heart disease for women is over 55 years of age (in men over 45). The incidence of coronary heart disease in women increases with age: women under 30 years of age suffer every twentieth person, while in the age group of 50-59 years, signs of coronary heart disease are in one of five women, after 60 years the overall incidence of coronary artery disease is 41.3%. Conclusions. The isolation of risk factors in stratifying the risk of cardiovascular disease and determining the markers of subclinical atherosclerosis in women will help to prevent the emergence of early complications of cardiovascular damage, reduce their morbidity and mortality.

14-17

Authors: Shevaga V., Payenok A., Zadorozhnyj A., Zadorozhna B.

Introduction. Today, doctors in general practice observe the steady growth of chronic diseases of the internal organs, which lead to violations of the normal functioning of the central nervous system with the gradual emergence of encephalopathy. Metabolic encephalopathies include brain damage due to homeostasis disorders in organs in the case of chronic kidney disease. However, the appearance of renal encephalopathy provokes not only toxic and metabolic disorders, but also arterial hypertension, which is a companion of chronic kidney disease. Aim. To study the psycho-emotional changes in patients with renal encephalopathy by the standardized multivariate personality examination (SMPE). Materials and methods. 20 patients with renal encephalopathy were examined, among them 8 men (40.0%) and 12 women (60.0%) aged from 24 to 43 years (serum age 38.73 ± 0.76). According to ICD-10, chronic kidney disease stage I was in 5 (25.0%) of the examined patients with renal encephalopathy, stage II – in 8 (40.0%), III – in 4 (20.0%), and IV – in 3 (15.0%). The control group was made of 22 practically healthy persons of the corresponding age. For a quantitative and qualitative assessment of changes of the psycho-emotional sphere of patients with renal encephalopathy, the SMPE method, being the Minnesota Multiphasic Personality Inventory (MMPI) and adapted by L. N. Sobchik to our conditions, was used. Results. A floating profile of Minnesota Multiphasic Personality Inventory was found in the examined patients in which most scales were above the upper limit of standard. The studied profile signifies the state of general stress which involves different mechanisms and compensatory functions of psychic activity which are under the tension. These are directed for the discrimination of dysadaptation. Although with this profile mental tension increases, this prognostic profile is promising in terms of normalization, as in this case a psychogenic borderline conditions caused by chronic somatic diseases are observed. In particular, the increased level of anxiety, uncertainty in oneself, the concentration of negative experiences, the presence of affective perversity of manifestations of inhibition and psychoasthenic response to external stimuli within the limits of neurotic disorders in the surveyed testify the high level of scores on the scale 6 and 7 in comparison with the control group (p <0.05). The presence of health problems in the patients with nephrotic encephalopathy and the absence of significant co-participation and help from others causes their autisation, the separation from reality (scale 8) (p <0.05 comparatively with a control group). Conclusions. Patients with renal encephalopathy often have anxiety-asthenic syndrome, and therefore such patients need the social support, which will facilitate their return to normal, active daily life.

31-35

Authors: Nyankovskyy S., Iatsula M., Senkevich O., Pasichnuk I., Kulik I.

Introduction. The health of the nation is determined primarily by the health of children. The results of numerous studies show that the source of the differences in adult health should be sought in their childhood. Children’s health is an integral indicator of the general well-being of society, as well as a subtle indicator of all social and environmental problems. Recently, the situation with the health of children has come close to the critical one: the general level of morbidity and the prevalence of diseases of organs and systems is increasing. Aim. To evaluate the medical and social features of the health status of schoolchildren in Lviv and Lviv region, to determine their dependence on age and place of residence. Materials and methods. The analysis of the results of the surveys made in 2002 (about 20,000 schoolchildren in Lviv) and in 2012 (about 32 000 children of Lviv and 16 000 children of four districts of Lviv region) were considered. The main risk factors of the formation of functional disorders, syndrome of school maladaptation, neurotic reactions, age prevalence of major complaints were discussed. Results. The study of the state of children’s health, taking into account their individual age characteristics at all stages of their development, with the simultaneous determination of the influence on the children’s organism of the various factors of micro- and macrosocium plays an important role in the optimization and complex principles of the organization of scientific research of such an important direction of pediatrics as preserving the health of the child. It is impossible to create an effective system of preventive, organizational and other technologies aimed at improving and preserving the health of children without taking into account the complexity of the main risk and protection factors. Analyzing the results of questionnaires, we can conclude that in recent decades, the state of health of schoolchildren in the Lviv region has no tendency to improve. Among the factors that lead to a decrease of the level of child health, the most important role belongs to the school workload, due to the stressful action of which there is a maladaptive syndrome with neurotic reactions of varying degrees of severity. A screening survey of schoolchildren, conducted on a large sample, enables us to identify the main medical and social features of schoolchildren’s life, to assess the age-old prevalence of major complaints and threatening symptoms, the main trends in their habits, to distinguish risk groups for further in-depth review and survey. Comprehensive assessment of the health of children, the introduction of new health-improving technologies, the unification of efforts of health workers, pedagogues and parents will help to prevent the growth of functional disorders and organ lesions in schoolchildren, their chronization, reduce the symptoms of school maladaptation, and increase their health. Conclusions. Among the factors that assist the decline of child’s health level the educational loading plays an important role. Its stress making effect results in fast development of the disadaptation syndrome with the neurotic reactions of different degree of expressiveness. The complex estimation of the children’s health state and introduction of new health promotion technologies give an opportunity to prevent the increase of functional disorders and organic pathologies in schoolchildren.

41-44

Authors: Markin L., Medvjedjeva O.

Introduction. Anomalies of the heart and major vessels of the fetus take the first place in the structure of mortality from the abnormalities developed in the early neonatal period, they occur with a frequency of 7 to 17 per 1000 newborns and cause about 40.0% of perinatal losses. Given the fact that preventative measures for the prevention of congenital heart diseases are not successful, their prenatal ultrasound diagnosis is relevant. There are cardiological abnormalities that are incompatible with life – in these cases, it is proposed to interrupt pregnancy. There are heart defects that can serve as markers for chromosomal abnormalities. Some variants of the congenital heart diseases can be adjusted by surgical intervention immediately after birth (such patients must be born in specialized centers). In addition, modern medicine is at such a stage of development that some structural anomalies of the heart can be eliminated even during the intrauterine period of the life of the fetus with the best pathway. Aim. To improve the diagnosis of fetal heart abnormalities during the routine screening ultrasound. Materials and methods. Recommendations for the improvement of the diagnosis of fetal heart anomalies by the routine screening ultrasound examination in the second trimester of pregnancy by the additional visualization of the major vessels with an assessment of the average diameter, the location of the heart axis, the ratio of the chambers of the heart and the size of the pulmonary artery, aorta and upper vena cava. Results. It is believed that the results of prenatal research is mainly influenced by the technical reasons (resolution of the device, pregnancy period, thickness of the anterior abdominal wall of the mother, position and size of the fetus). In our opinion, the prenatal detection of congenital heart defects strongly depends on the algorithm of conducting a fetal heart study in the screening regimen. All screening ultrasounds should be performed according to a single protocol, which is the main for the standardization of echographic research. In the case of suspicion of airborne disease in the fetus, the patient is referred for medico-genetic counseling with karyotyping and verifying the diagnosis. The main screening examination of the heart is based on a four-chamber cut. To obtain this image, the sensor should be installed perpendicularly to the fetal ridge at the level of atrioventricular valves. During the adequate withdrawal of this section, the right and left ventricles, right and left atrium, interventricular and interatrial septum, mitral valve and tricuspid valve openings are clearly visualized (the level of the tricuspid valve is normally slightly lower than mitral), an oval window can also be seen. Conclusions. During the additional visualization of the major vessels more than 90.0% of congenital heart defects can be diagnosed, indicating the need to optimize the protocol for the providing of the assistance of such patients, and the basic specific criteria for evaluating the anatomy of the heart and the fetal heart. So, the study of fetal heart is one of the most important stages of screening ultrasound in the second trimester of pregnancy.

49-51

Authors: Katerenchuk O.

Introduction. According to the World Health Organization (WHO) Report currently more than 350 million people in the world suffer from clinically significant anxiety and depressive disorders and this number is expected to grow. Depression is the leading cause of disability worldwide. The special attention should be given to the category of patients with the cardiovascular diseases, because the existence of depression greatly deteriorates the disease course. It is well-known that depression and anxiety are the risk-factors for the development of cardiovascular diseases. Also depression is usually observed in patients in early post-myocardial infarction period, in patients with hypertension, especially with the heart failure syndrome. Aim. To analyze the literature sources and to propose own thoughts on the topic of the depression and cardiovascular diseases, their causes, consequence or comorbidity. Materials and methods. Content analysis, method of system and comparative analysis, bibliosemantic method of research of actual scientific researches on the topic of the depression and cardiovascular diseases, their causes, consequence or comorbidity was made. Results and discussion. The combination of depression and cardiovascular diseases is a well-known clinical fact, supported by the results of many clinical studies. Since the 90’s more than 100 descriptive studies in this field assessing the relationship of depression with cardiovascular morbidity and mortality have been performed. Also more than 60 prospective studies were conducted to establish the connection between the presence of depression and coronary heart disease. It is important to note that the negative impact on the prognosis has not only the so-called major depression, but also its mild form. Women are 1.7 times more likely to experience a significant depression than men. The majority of clinical studies of depression in patients with heart failure do not provide a separate data for men and women. One study analyzed the prevalence of depression in patients with heart failure only in out-of-hospital settings. The symptoms of depression were observed in 64 % of the women and 44 % of the men. Interestingly, the hospitalization for treatment of acute heart failure usually exacerbates the symptoms of depression. Once the heart failure is under control, the depressive signs and symptoms may abate. There are different pathological mechanisms of depression in cardiovascular diseases. The first is the psychological aspect associated with the development of life-threatening condition. The feeling of fear of death, anxiety about the future course of the disease, restrictions of physical activity, necessity of the invasive procedures usually cause anxiety and\or depression in patients in the acute phase of the disease. For the early post-myocardial infarction patients’ depression substrate more often is due to the impossibility of returning to normal physically active life, reduced work capacity, social adjustment difficulties and the impact of myocardial infarction on sexual activity. At the same time, despite the psychological mechanisms of depression, the dysfunction of the heart muscle also attributes to the development of depression. Myocardial dysfunction is usually observed in cardiovascular diseases (coronary heart disease, arterial hypertension, cardiomyopathy, inflammatory heart diseases, valvular lesions). Also the myocardial dysfunction in the form of heart failure is the final link in the chain of cardiovascular continuum. Any damage to the heart muscle leads to the increasing of the filling pressure in the heart chambers and thereby stimulates the increased activity of neurohumoral systems: the rennin-aldosterone-angiotensin, sympathetic nervous system, vasopressin and natriuretic peptides systems. Activation of neurohumoral systems aims to support the adaptation processes and homeostasis in heart failure syndrome but often causes harm. In the settings of the heart failure syndrome we should also mention the endogenous cannabinoid system, which as a system of the immediate response to stress, after the period of overstimulation becomes depleted causing a paradoxical effects. At the same time, depressive disorders are often accompanied by the hyperactivity of the hypothalamic- pituitary-adrenal axis, followed by increased excretion of cortisol in the bloodstream. Increased cortisol in this situation has a protective effect by mobilizing the body’s reserves. Interestingly, the higher levels of blood coagulation are observed in patients with cardiovascular disease and depression in comparison with patients without depression. Conclusions. The depression in terms of cardiovascular diseases may act as a risk factor for their development, it can be a cause of the heart muscle dysfunction, as well as be caused by psychological problems in consequence of the disease.

57-60

Authors: Ilnyckyу G., Bilozir L., Bojko O., Chulovska U., Nevzhoda O.

Introduction. At the stage of the unceasing progress of science and technology, the quality of education, and hence the use of innovative technologies, makes it possible to improve it. In the educational sector of Ukraine, the Concept for the training of the physicians is being developed, elaborated in accordance with the requirements of the World Federation of Medical Education and the main provisions of the Bologna Process. The educational sector, like medical education in particular, has entered the path of radical reforms and entry into the European educational space, requires the bringing of all of itscomponents to the generally accepted international standards. One of the initiators of the implementation of reforms and innovations into the medical and educational sector of Ukraine is the Danylo Halytsky Lviv National Medical University, the oldest medical institution of the country’s education, founded in 1784. Aim. To highlight the teaching methodology of the discipline “tuberculosis” for the students of the English-speaking form of education using computer-information technologies. Materials and methods. The experience of the Department of Phthisiology and Pulmonology in conducting the educational process among the students of the English-speaking form of education is described. The achievements, problems and ways of their improvement in conditions of joining the European educational space are considered. Results. The work of the staff of the Department of Phthisiology and Pulmonology of the Danylo Halytsky Lviv National Medical University in a complex with modern equipment of educational rooms and lecture rooms, dynamic provision of pedagogical process is provided taking into account the latest information technologies, systematic updating and replenishment of materials, including bench and test tasks, as well as comprehensive publishing of the activities and not only improve the quality of the educational process, but also the growth of students’ interest in the subject “Tuberculosis” highlighting the problems of tuberculosis, which positively affects the prospects of the further professional orientation of future doctors. Conclusions. Achievements in the field of obtaining modern medical education in higher educational institutions of Ukraine will facilitate the attraction of new foreign citizens to study. High professionalism and spirituality, the achievements of the Ukrainian, in particular, Lviv medical school, can serve outside of our country. Ukraine, in keeping with the global educational trends, will have a worthy place in the modern information world.