ARTICLES ARCHIVE

In 2016, the European Society of Cardiology presented five new texts of recommendations. The group of experts under the leadership of P. Ponikowski prepared recommendations on diagnosis and treatment of acute and chronic heart failure. The measures aimed at correcting heart failure risk factors in order to prevent its occurrence and extend the life of the patient were proposed. For the first time, the treatment algorithm includes Sacubitril/Valsartan (LCZ696). The new document says that three−chamber pacemaker implantation for resynchronization therapy in chronic heart failure with left ventricular ejection fraction less than 35 % is contraindicated in patients with a QRS duration less than 130 ms. The recommendations for atrial fibrillation treatment are an entirely new text, which emphasizes the importance of intensive screening to identify it in people over the age of 65, especially in those who survived stroke or transient ischemic attack, by recording electrocardiogram. A complex approach to treatment including urgent deceleration of ventricular rate or sinus rhythm restoration; correction of provoking factors; stroke prevention, etc. was suggested. The new text of the recommendations on prevention of cardiovascular disease in addition to the measures at the individual level, emphasizes the importance of population prevention: smoking cessation, healthy nutrition, physical activity, limiting alcohol consumption, and environmental improvement. For the first time, the text is supplemented by the measures of cardiac rehabilitation in patients after acute coronary syndromes. The main therapeutic measures at dyslipidemia include lifestyle changes and pharmacotherapy. It recommended to administer satins up to the maximum dose to achieve target LDL levels. An interesting innovation is optionality of fasting blood sampling to determine cholesterol levels. For the first time, a consensus document on cardiovascular toxicity of cancer treatment was prepared. The objective of cardiooncology is prevention, detection and treatment of cardiovascular complications resulting from cancer therapy. Cardiotoxicity in cancer patients is recommended to correct for the type of complication, the supposed cause, competing risk of death of cardiovascular disease and cancer, quality of life. The next Congress of the European Society of Cardiology is planned to be held in Barcelona (Spain) in August 2017.

An important problem of contemporary cardiology is diagnosis of cardiovascular diseases at the preclinical stage. The vessels are one of the main target organs affected with cardiovascular diseases. Establishing the arterial wall lesion and its rigidity is essential for the practice of medicine, with which purpose ultrasound investigation is used. Modern technology of radio frequency analysis (echotracking) helps to track the movement of the walls of major arteries. There are two software applications: to measure the thickness of the intima−media complex and to determine vascular stiffness (usually of the carotid arteries). High accuracy, independence from the operator, the ability to monitor reliability of the measurements are important advantages of the new method. Echotracking is also used successfully to determine the effectiveness of the drugs administered. Active introduction of a new noninvasive ultrasound investigation of the common carotid artery with echotracking based on radio−frequency analysis of the movement of the major vessel walls during the passage of the pulse wave will contribute to successful diagnosis and treatment of cardiovascular diseases, reduction of morbidity and mortality.

It is known that even a slight increase in the level of thyroid−stimulating hormone is a significant predictor of liver steatosis, disorders of carbohydrate and lipid metabolism which creates preconditions for detailed investigation of the combined course of non−alcoholic fatty liver disease (NAFLD), arterial hypertension and subclinical hypothyroidism. To study the influence of NAFLD on endothelial function in patients with hypertension and subclinical hypothyroidism we investigated 75 patients. The study protocol included anthropometric data evaluation, measurement of mean arterial pressure, concentration of thyroid hormones, lipid and carbohydrate metabolism indices, assessment of vascular endothelium condition and its degree of damage. Antioxidant system was evaluated by glutathione peroxidase activity and the level of sulfhydryl groups (SH−groups), the level of malondialdehyde (MDA) was used as a marker of the oxidative stress severity. Our findings suggest that the changes in the level of circulating endothelial cells in patients with hypertension and subclinical hypothyroidism is associated with severe dyslipidemia, insulin resistance and confirm higher risk of developing cardiovascular complications in these patients. The course of hypertension combined with subclinical hypothyroidism and nonalcoholic fatty liver disease produces abnormal metabolic phenotype characterized by the presence of dyslipidemia, hyperinsulinemia and insulin resistance against a background of oxidative stress and endothelial dysfunction. Significant changes of vascular endothelial dysfunction markers in patients both with combination of hypertension and subclinical hypothyroidism and in greater extent, when associated with NAFLD, indicate that this category of patients has a high cardio−vascular risk. The study of endothelial function, oxidative stress against a background of hormonal and metabolic parameters will contribute to better understanding of common pathogenetic processes of a combined course of hypertension and subclinical hypothyroidism, will help to assess the extent of increase in cardiovascular risk when non−alcoholic fatty liver disease accedes, to predict the characteristics of comorbid course of these diseases.

Hypertensive disease and chronic obstructive pulmonary disease are common around the world; they are characterized by chronic progressive course and require lifelong treatment. Development of chronic heart failure as a result of cardiovascular diseases and complicated COPD is a well−known phenomenon. To study the question of the ways of development of chronic heart failure in the presence of the pathology of the cardiovascular and respiratory systems we estimated systolic and diastolic function of the heart chambers in patients with COPD and hypertonic disease. Left ventricle diastolic and systolic diameters, posterior wall thickness, interventricular septum, left ventricular ejection fraction were measured at ultrasound examination. LV myocardium mass was calculated by Devereux R. et al. Diastolic function of the both ventricles was assessed using pulsed Doppler study and fractional area change. The findings showed that the comorbidity was characterized by moderately severe systolic dysfunction in the left ventricle, right ventricular hypertrophy. The study of velocity values of the both ventricles revealed type I of diastolic dysfunction. The patients with concomitant hypertension disease had more pronounced changes in the myocardium, mainly the left portion. The mechanisms underlying myocardial restructuring, require further study. Identification of precipitating factors and factors of progression of myocardial dysfunction can be of great interest. Investigation of interventricular relationship in development of heart failure in patients with chronic obstructive pulmonary disease and concomitant hypertension, as well as structural and functional assessment of the myocardium during the comorbid disease will open new perspectives in treatment and prevention of disability in patients with cardio−pulmonary pathology.

At present, marker levels are investigated with the purpose of differential diagnosis and treatment of community−acquired pneumonia (CAP) in conjunction with chronic heart failure. To study the dynamics of pro−inflammatory (IL−1?, IL−8, TNF−a), anti−inflammatory (IL−10) cytokines and markers of inflammation CRP in patients with CAP combined with or without heart failure, and their impact on the course of CAP we investigated 105 patients aged 42−73. The levels of pro−inflammatory, anti−inflammatory cytokines in patients were determined on the day of admission to therapy department and two or three days later, by method of immunoenzyme assay. The feature of the course of CAP in patients with chronic heart failure is increased content of CRP in the blood serum in early disease compared with the patients with chronic heart failure without pneumonia, which persists 48−72 hours from the treatment onset. Two−three days after the onset of antibiotic therapy, the content of CRP in patients with САР and heart failure exceeds the concentration of CRP in patients with САР without chronic heart failure. The patients with САР, chronic heart failure and combined pathology were characterized by elevation of IL−10 and reduction of IL−8 and CRP. Our findings show that heart failure negatively affects the clinical course and prognosis in patients with CAP and increases the risk of unfavorable outcome. The interest in the dynamics of the indicators of inflammation: pro−inflammatory, anti−inflammatory cytokines and inflammation marker CRP in patients with mild CAP accompanied by CHF is due to the necessity to find the ways to improve the diagnosis and treatment of it.

This review presents the results of literature search on existing methods and approaches to formation of esophagogastrostomy in patients with diseases of the esophagus. It is stated that esophageal reconstruction after esophagectomy remains a major problem in surgery of the esophagus, and the problem of reliability of the junction remains urgent until now as anastomotic failure is a common cause of deaths. The purpose of the work was to analyze the advantages and disadvantages of various types of esophagogastrostomy in patients with diseases of the esophagus. The authors describe the variants of forming esophagogastrostomy by location, method and technique features of anastomoses. Advantages and disadvantages of contemporary techniques and methods of formation of esophageal−gastric anastomoses, submersible, plastic, invagination anastomoses, which are formed using two−three−lane stitches and anastomoses performed using suture devices, are described. A newly developed by National O. O. Shalimov Institute of Surgery and Transplantology method of mechanical invagination esophagogastrstomy is described. Criteria for assessment of the effectiveness of the method were formulated. The findings of the research suggest that the method of forming esophageal anastomosis is a separate important issue of esophageal surgery. Despite the presence of numerous developments concerning the methods of esophagogastrostomy, a number of its aspects are controversial and a perfect anastomosis has not been created yet. The work with scientific sources suggests that the final result depends not only on the used method, but also on the experience of the surgeon and accuracy of the technical performance of the chosen method, individual approach to the patient and relevance of the method to the principles of optimal healing of anastomosis.

Lymphorrhea follows 100 % of radical mastectomy cases. The purpose of the study was to improve the results of surgical treatment of patients with breast cancer by preventing development of postmastectomy lymphorrhea and its unfavorable course. Comparative analysis of the results of treatment of patients with breast cancer who underwent radical surgery using the classical technique was done. In the patients who were performed electro−technology, it was possible to reduce the period of the last drainage, the term of parenteral analgesic therapy, to reduce the frequency of partial failure of post−operative wounds, to avoid postoperative wound suppuration, to decrease the incidence of seroma formation, and in case of post−operative complications they were eliminated using conservative methods.

Autoimmune thyroid diseases occupy an important place among pregnancy complications. Timely diagnosis of thyroid pathology in pregnant, especially its subclinical forms, as well as prevention and treatment reduce the incidence of diseases in pregnant and newborns. At present, great attention is paid to the problem of investigation of hemostasis system as an important link in thyropathy development. To define the features of changes in the system of hemostasis in pregnant with autoimmune pathology of the thyroid gland, we investigated the patients with euthyroidism, hypothyroidism and autoimmune hyperthyroidism. General clinical examination of patients was performed; main indices of the coagulation system were studied in the dynamics of gestation. The findings of the research suggest that all pregnant with thyroid pathology, especially with subclinical course, have changes in system of hemostasis. The patients with hypothyroidism and autoimmune hyperthyroidism are characterized by chronometric and structural hypercoagulation, which does not develop at physiological pregnancy of the respective terms of gestation. It manifests in pregnant with hypothyroidism by chronic DIC syndrome, and in pregnant with hyperthyroidism by subclinical DIC syndrome. Structural hypocoagulation is typical for pregnant with euthyroidism. The research findings indicate that pregnant with thyroid pathology have pathological activation of the hemostasis system, which is one of the causes of obstetric and perinatal complications. Development of pathogenetically substantiated methods of prevention and treatment of autoimmune thyropathy can reduce obstetric and perinatal complications.

Aneuploidy is designated as an abnormal number of chromosomes. The presence of one additional chromosome (trisomy) leads to congenital anomalies of the fetus. Trisomy 21 occurs much more frequently than the rest and is a major cause of mental retardation. Nondisjunction of the chromosomes of the 21st pair during the ovocyte division causes Down's syndrome in 95 % of cases. Trisomies 18 and 13 are less common and are considered lethal abnormalities. Ultrasonography has been used successfully in antenatal diagnosis of trisomy 21 in 80 % of cases, trisomies 18 and 13 in 90−100 %. Ultrasound screening used in the 1st trimester of pregnancy allows chorionic villus sampling to diagnose aneuploidy, and is case it is confirmed, it is considered the reason for abortion. The methods for trisomy 21 risk assessment are ultrasound of the cervical area, fetal nasal bone; Doppler venous flow investigation, analysis of serum pregnancy−related protein markers of the mother, and subunits or the whole molecule of human chorionic gonadotropin. Screening in the 2nd trimester includes ultrasound detection of fetal anomalies and determining the levels of alpha−fetoprotein, beta hCG conjugated estriol and inhibin−A in the blood serum of pregnant. Reasonability of expert advice for choosing the most suitable trisomy risk assessment algorithm is emphasized.

Polyarteritis nodosa (PAN) refers to a systemic vasculitis of medium−sized vessels, and the renal changes are determined by stenosing processes and development of microaneurysms of the renal vessels, that drastically reduces survival rate of the patients. To determine the frequency of kidney damage in PAN, to estimate relationships with extrarenal manifestations of the disease and the pathogenesis of nephropathy, the patients with polyarteritis nodosa accompanied by nephropathy were investigated. Total protein, fibronectin, ?2−microglobulin, creatinine, urea, uric acid and nitrite in the urine were studied, physical and chemical superficially active, viscoelastic and relaxation properties of the urine were determined; renal ultrasound, ultrasound of the vessels and renal angiography were performed. Kidney damage occurred in 62 % of patients with polyarteritis nodosa, that in 42 % of cases was followed by renal failure, that depended on the age and sex of the patients, pathology of the skeletal muscles, endocardium, cardiac valvular apparatus and peripheral nervous system (polyneuropathy), the nature of the course and the degree of activity of the disease, the presence of viral hepatitis B antigen and some cardiovascular indicators (peripheral and pulmonary vascular resistance, the size of the left atrium, the diameter of the brachial artery during vasodilation), and rates of progression of nephropathy were closely related to blood levels of C−reactive protein and rheumatoid factor, that have some predictive value. Nephropathy is a frequent manifestation of PAN requiring development of criteria for early diagnosis and prognosis of renal pathology in such patients.

At present, urolithiasis is one of the most frequent diseases. Selecting the optimal method of treatment of ureteral stones always requires consideration of a large number of factors: the features of the stone (location, size, density, availability and duration of obstruction), clinical features (severity of the disease, the patient's preferences, comorbidities), anatomical features (presence of congenital and acquired abnormalities in the kidneys and ureters), technical features (available equipment, the surgeon's experience, the procedure cost). Comparative analysis of the treatment of patients with ureteral stones was performed using ureteroscopy and contact ultrasound lithotripsy. The data about the failures and complications encountered in the treatment of ureteral stones using miniinvasive surgery are reported. The frequency of intraoperative complications when using this method of treatment did not exceed the well−known standards. Post−operative complications of ureteroscopy were not severe and resolved by therapeutic methods. At the same time, it is concluded that due to the fact that elimination of complications of ureteroscopy significantly increases the cost and duration of treatment, prolongs the patient's disability, further analysis of the causes of failure and complications at ureteroscopic treatment of ureteral stones, as well as the search for the ways to minimize them are necessary.

To date, prostate cancer, the mortality at which has increased by 16 % in recent decades, is considered one of the most socially significant oncological diseases in the world. Metabolic syndrome, a set of risk factors including obesity and insulin resistance, is widely thought to be implicated in development of prostate cancer. But its impact on androgen deprivation therapy (ADT) efficacy has not been studied. With this purpose we performed a retrospective investigation of 102 prostate cancer patients in whom MS was assessed at the time of initiation of ADT. The study end points were time to prostate−specific antigen (PSA) progression and overall survival from time of starting ADT. The results showed that mean period until PSA progression in patients with metabolic syndrome was 16 months, without it 36 months. The life expectancy of patients with metabolic syndrome made 36.5 months from ADT onset, while in patients without it was 46.7 months. This preliminary data suggest that MS is a risk factor for earlier development of castration−resistant prostate cancer and support the need for prospective evaluation of this finding.

Sleep disorder is one of the most common complaints in patients with myofascial pain syndrome and vertebral artery syndrome. In myofascial pain syndrome, sleep disorders are most commonly caused by the reflected pain resulting from compression of trigger points during sleep or shortening of the affected muscles. According to many authors, the leading role in development of sleep disorders accompanying vertebral artery syndrome, is played by dyshemic disorders in the brain stem, and located in it ascending activating reticular structures, regulating sleep and wakefulness. The quality of sleep and features of its disorders were investigated in 75 patients with myofascial pain syndrome of neck and shoulder location and vertebral artery syndrome resulting from it. Insomnia Severity Index, Epworth Sleepiness Scale were used. Severity of pain was assessed using visual analog scale. The musculotonic disorders were assessed on the basis of calculation of muscle syndrome index. To assess vertebral−basilar insufficiency Hoffenberth scale was used. In patients with myofascial pain syndrome of cervicobrachial location and vertebral artery syndrome accompanying it, sleep disorders consisting in difficulties in falling asleep, interrupted sleep, early final awakening, as well as daytime sleepiness were identified. A positive correlation between the severity of the musculotonic disorders, the pain severity and insomnia severity was found. Sleep disorders in the patients with comorbidity were characterized by more severe form of falling asleep at night, frequent waking up at night, early final awakening, and more pronounced daytime sleepiness. Severity of insomnia directly correlated with the score by B. Hoffenberth et al. scale. Combination of myofascial pain syndrome located in the neck and shoulders and vertebral artery syndrome significantly increases severity of dyssomniac disorders and daytime sleepiness, which should be considered when dealing with this category of patients. The problem of sleep disorders in vertebral artery syndrome requires further investigation in order to develop optimal treatment strategies.

This comparative investigation of the prevalence and morbidity in children from Kharkiv region and Ukraine as a whole, in particular, urban and rural residents, was conducted in order to improve the medical care for children with disorders of the nervous system and epilepsy. Statistical and analytical methods were used in the study. The prevalence of the nervous system diseases in children in Kharkiv region and Ukraine was 86.28 % and 53.53 %, respectively. The ratio of the prevalence of nervous system diseases in children from urban and rural areas of Kharkiv region was 7:10, in Ukraine −− 3:1. The prevalence of epilepsy in Ukraine was 3.21 %, in Kharkiv region −− 3.43 %. In Ukraine the prevalence of epilepsy in urban children was significantly higher vs. Kharkiv region. The incidence of diseases of the nervous system in Ukraine was 18.45 %, while in Kharkiv region it was 28.07 %. The nervous system diseases in children prevailed among the urban population of Ukraine (4:1), while in Kharkiv region no significant difference was detected. In Ukraine epilepsy incidence made 0.43 %, while in Kharkiv region −− 0.45 %. The incidence of epilepsy predominated among the urban population of Ukraine (3:1). These results allow to analyze a group of patients with nervous system diseases and epilepsy under 18 years of age, to determine a number of epidemiological indicators in Kharkiv region and Ukraine. The obtained findings confirm the prevalence of diseases of the nervous system and epilepsy among urban residents in Ukraine as well as more uniform distribution of the prevalence and incidence of epilepsy and nerve diseases among urban and rural residents of Kharkiv region. The necessity to improve organizational forms of neurological and antiepileptic services, especially in rural areas, which can promote improvement of the quality of life and prevention disability of patients, is emphasized.

The relevance of Epstein−Barr virus infection is caused by a high degree of infection of the population not only in Ukraine but also all over the world, as specific antibodies to that virus are detected in almost 95 % of the adult population. To establish the types of immune reaction for prognosis of the clinical course of disease in patients with various forms of EBV−infection we analyzed the dynamics of multidirectional synthesis of cytokines (IL−1?, TNF−?, IL−6, IL−2, IL−4 and IL−10). Four types of immune reaction: I −− normoreactive type (significant increase in pro−inflammatory and anti−inflammatory cytokines), II −− dissociative (high levels of pro−inflammatory cytokines and low levels of the regulator cytokine IL−2 and anti−inflammatory cytokines), III −− hyporeactive (low concentrations of both pro−inflammatory and anti−inflammatory cytokines), and IV −− hyperreactive (high concentrations of both pro−inflammatory and anti−inflammatory cytokines) were distinguished in patients with EBV−infection. The obtained findings allowed to conclude about the existence of cytokine imbalance in EBV−infection. The established types of immune reaction testify to inadequate cellular−humoral reactivity of the organism under the conditions of persistent EBV−infection manifesting suppression of cellular−mediated and intensification of humoral mechanisms of immune response and reflected in clinical−biochemical manifestations of the disease that results in prolonged intermittent course. It is the functional imbalance of immunity links towards priority of Тh2 type production, which biological effects are directed to limitation of intensity and prevalence of inflammatory process in different organs, that promotes prolongation of viral persistence.

The problem of toxoplasmosis is relevant due to the disease prevalence in the world. The lack of universal treatment protocols necessitates an individual approach to the use of different forms of therapy for chronic acquired toxoplasmosis. For this purpose we performed comparative assessment of the dynamics of indicators of immunological protection in patients under the influence of various types of complex therapy. Diagnostic criteria of exacerbation stage of the disease were the clinical symptoms and instrumental findings. The efficiency of complex treatment of exacerbation stage of chronic acquired toxoplasmosis was studied using antiprotozoal therapy with a combined drug pyrimethamine + sulfadoxine, specific immunoglobulin against human Toxoplasma and their combination on the basis of investigation of the dynamics of clinical and laboratory, instrumental and immunological data. In this disease, the effect of the therapy was assessed no earlier than one month after the comprehensive treatment, and then 6 months after it. The maximum therapeutic effect was determined from the 6th month of treatment onset. Pronounced dynamics of indicators was noted in patients receiving combination therapy, moderate −− replacement therapy with immunoglobulin against Toxoplasma gondii, and inconsiderable −− in patients treated with pyrimethamine + sulfadoxine.

The majority of multiple fractures require immediate surgery, the amount and timing of which depend on many factors, namely equipment of the hospital, experience of the surgeon, possibility to correct homeostasis, modern anesthesia, etc. Thus, the issue of choosing the most adequate and effective anesthesia method which can allow not only to achieve the desired level of analgesia during the surgery, but also effectively correct postoperative pain, is urgent. The technique and effectiveness of regional anesthesia followed by epidural and plexus analgesia using disposable elastopomp in patients with multiple fractures of the extremities were analyzed. The quality of anesthesia was determined by a survey of the surgical team, assessment of pain by the post−operative patients using visual analog scale, quality of life in the post−operative period. Surgical interventions on the upper and lower extremities were performed under brachial plexus blockade and under subarachnoid anesthesia in accordance with the subsequent addition to the catheters of disposable elastopomps with 0.125 % solution of bupivacaine for postoperative analgesia. The elastopomps were removed on the third day after surgery. In all cases, an adequate level of analgesia of the operated limb was obtained. Intra−operative analgesia fully satisfied the surgeons during the surgery. The need for administration of opioids was absent. The quality of life after simultaneous fixation of multiple fractures of the upper and lower extremities completely satisfied the patients throughout the post−operative period. Thus, the issue of choice of most adequate and effective anesthesia promoting the desired level of analgesia during the surgery as well as effective correction of post−operative pain is urgent.

The present work investigates development of a new approach to providing postoperative analgesia during surgery for esophageal cancer. To improve the results of surgical treatment of patients with malignant diseases of the esophagus, a method of management of postoperative analgesia was developed and applied in the patients who were performed radical surgery with combined thoracoabdominal approach (Lewis or Garlock−Osawa) and who were administered post−operative anesthesia in the form of thoracic epidural analgesia and thoracic paravertebral block. The patients were performed clinical and laboratory investigations, monitoring of urine output. Intensity of pain was assessed using Visual Analogue Scale and FPORS−scale (four point observer ranking scale). The parameters of acid alkaline and blood gas status, respiratory and hemodynamic performance, clinical and biochemical blood count were evaluated. The proposed method consisted in insertion of 1 catheter at the level of Th5−Th7 before the surgery, and the other during the surgery in the paravertebral space at the level of throracotomy. The improved method of combined postoperative analgesia using thoracic epidural anesthesia and thoracic paravertebral block proved its effectiveness in control of pain and absence of complications such as hypotension and respiratory disorders.