№4' 2017


Dnipro Medical Academy, Ministry of Health of Ukraine, Ukraine
Daily monitoring of blood pressure and structural and functional state of the heart in middle−aged and elderly patients with arterial hypertension
5 - 12
Arterial hypertension is an independent and most important factor in cardiovascular disease development and causes a high risk of disabling complications and mortality. The age−related features of changes in daily profile of blood pressure and parameters of the structural and functional state of the heart were determined in middle−age and elderly patients with arterial hypertension using the data of long−term investigation. Assessment of the structural and functional state of the heart was performed using transthoracic echocardiography, a pulse−wave Doppler device by the standard method. The features of daily blood pressure profile were analyzed according to the daily blood pressure findings. After the initial examination all patients were administered antihypertensive therapy in accordance with the recommendations for the diagnosis and treatment of arterial hypertension. Further dynamic observation included daily blood pressure monitoring and echocardiography 3, 6 months and 1 year later. The dynamics of changes in the characteristics of the daily profile of arterial pressure and the structural and functional state of the heart was investigated in middle−aged and elderly patients with arterial hypertension against a background of a long−term treatment. The age−related characteristics of the course of arterial hypertension were determined. In elderly patients, it is advisable to use routine daily blood pressure monitoring to evaluate the effectiveness of the prescribed antihypertensive therapy. Regular dynamic monitoring and evaluation of the effectiveness of the chosen treatment tactics under daily blood pressure control allows not only to reach the target levels of the blood pressure, but also normalize the circadian rhythm of the blood pressure, which improves the prognosis of cardiovascular complications in hypertensive patients, especially in the elderly ones. At reaching the target level of the blood pressure in the group of middle−aged patients, reversion of left ventricle hypertrophy was achieved by 3rd month and the regress of myocardial hypertrophy reached its maximum by the 1st year of treatment. In the elderly patients, normotension can only be achieved at the absence of progress in the level of left ventricle hypertrophy.
Key words: arterial hypertension, daily blood pressure monitoring, left ventricular hypertrophy, left ventricular diastolic dysfunction, elderly age.
Kharkiv National Medical University, Ukraine
Correction of hyperglycemia, a predictor of endothelial dysfunction in petients with chronic heart failure
13 - 16
Heart failure (HF) is one of the most common and prognostically unfavorable complications of cardiovascular diseases. According to the European Association of Cardiologists, it occurs in 2−3 % of the general population. In patients with diabetes mellitus (DM), the course of HF is most severe, their mortality is 40−80 % higher than in those without DM. HF has been one of the most common chronic diseases in Ukraine over the recent 20 years. Numerous experimental and clinical studies have detected the increased level of endothelin−1 in plasma of the patients with chronic HF. HF has been noted as a concomitant diagnosis in 25−40 % of all patients with documented DM. Magnesium influences the functional state of endothelium, which takes part in the regulation of vascular tone, hemostasis, immune response, migration of blood cells to the vascular wall, synthesis of inflammation factors and their inhibitors and acts a barrier function. The aim of this work was to study the influence of hyperglycemia on endothelial dysfunction in patients with chronic HF and concomitant DM−2. The following tasks were set: to determine the character of changes in the endothelial function (endothelin−1, nitrite, nitrate) in patients with chronic HF, coronary artery disease and concomitant DM−2; to determine the impaired physical exertion tolerance and quality of life; to determine the features of changes of magnesium content with rates of endothelial dysfunction and glucose metabolism in patients with chronic HF and DM−2 in comparison with the patients with CHF without DM−2. The study involved 98 patients with chronic HF, of them 68 with concomitant DM−2. The control group involved 20 otherwise healthy subjects. Group 1 included the patients with chronic HF and DM−2 who received magnesium orotate (38 patients); group 2 included 30 patients with chronic HF and DM−2 who did not receive magnesium orotate; group 3 consisted of 30 patients with chronic HF without DM−2 who received magnesium orotate. All patients received therapy according to the standards of chronic HF and DM−2 treatment and recommendations of the European Society of Cardiology (ACE inhibitor −− lisinopril, ARA II, indapamide, aspecard, statins, hypoglycemic therapy) for 10−12 weeks. In the absence of contraindications, the patients of groups 1 and 2 were prescribed magnesium orotate 1000 mg tid for 7 days, then 500 mg bid additionally to the standard therapy. Repeated examination was performed after 12 weeks. The data analysis showed that endothelin−1 in the blood plasma of the patients with chronic HF and DM−2 was 3,5 % higher than in the group of patients with CHF without DM−2 and 32 % higher than in patients with chronic HF and DM−2 in the control group, the levels of NO2 and NO3 were significantly higher in patients with chronic HF without DM−2 by 26 % and 34 % respectively, which indicated a negative effect of hyperglycemia on the production of nitric oxide metabolites. Thus, the level of blood glucose and glycosylated hemoglobin was significantly higher in patients with functional class 3 (FC) of HF than in patients with FC 1 and 2 of HF. In patients with chronic HF and DM−2, addition of magnesium orotate to standard therapy reduced heart failure by 17,6 %, in patients with chronic HF and DM−2 who received only standard therapy, heart failure decreased by 7 %. In patients with chronic HF without DM−2, who received magnesium orotate, the functional class of CH decreased by 8 %. Thus, the presence of DM−2 aggravates the severity of heart failure.
Key words: chronic heart failure, type 2 diabetes mellitus, hyperglycemia, hypomagnesemia.
Dnipro Medical Academy, Ministry of Health of Ukraine, Ukraine
Pneumonia lethal outcome predictors in patients with oncohematological diseases
17 - 25
Significance of the problem of diagnosis and treatment of pneumonia in patients with a background of blood cancer is due to a high incidence, lack of clinical manifestations, severe course, frequent complications and rapid development of fatal consequences. Pulmonologists believe that assessment of pneumonia severity, based on the grade of the clinical manifestations, which allows to identify the patients in need of intensive care, determine the most optimal therapeutic tactics (the type and amount of antibacterial, detoxification therapy) and estimate the prognosis, is of the principal importance. To determine the predictors of pneumonia lethal outcomes in patients with immune disorders against a background of blood cancer, statistical analysis of a set of clinical, laboratory, history and immunological indices characterizing the course of pneumonia and the basic blood disease was performed. The archival data of 605 cases of in−patients with oncological blood diseases (2011−2014) were analyzed; 206 cases were investigated prospectively (2014−2016). The diagnosis of the nosological form of oncological blood disease and pneumonia were verified according to generally accepted clinical, radiological and morphological criteria. The features of the course of pneumonia were studied regardless of the phase of the disease. Formalized case reports of the patients, which included the results of clinical, instrumental and laboratory methods of investigation, including microbiological, main groups of antibacterial drugs, terms of their administration, were created. According to the results of the study, the equation of logistic regression of the prediction of pneumonia lethal outcome onset in patients with a background oncological blood diseases with 97,67 sensitivity, 100,0 % specificity, 0,999 area under the ROC curve, in which the most significant indicators were used: the presence of gram−negative pathogens of pneumonia, the number of erythrocytes; immunoregulatory index (СD4/СD8); the number of leukocytes; grade 3 neutropenia. and IgG, was obtained. Fatal prognosis is also caused by other indicators characterizing the underlying disease: anemia, thrombocytopenia, the number of chemotherapy (8 and more) courses. The use of the obtained logistic regression equation to predict pneumonia mortality in patients against a background of oncological blood disease allows to predict pneumonia lethal outcomes based on a few number of parameters that are available in hematological hospitals. This can help to timely optimize the treatment of pneumonia and reduce the mortality rate of the patients and duration of the hospital stay.
Key words: pneumonia, immunity disturbances, oncohematological diseases, prognosis, lethal outcome.
Kharkiv National Medical University, Ukraine
Participation of polymorphism of A1166C gene of type 1 angiotensin II receptor in metabolic disorders in patients with arterial hypertension and non−alcoholic fatty liver diseases
25 - 29
The urgency of investigation of the combination of arterial hypertension and non−alcoholic fatty liver disease is due to the high incidence of life−threatening complications caused by these diseases. Arterial hypertension and non−alcoholic fatty liver disease are comorbid diseases, which implies their interconnectedness and mutually complicating effect. Recently, much attention has been paid to the issues of the participation of gene polymorphisms in the development and progression of multifactorial diseases. Consideration of the specific version of the gene polymorphism in patients contributes to the maximum individualization of the diagnosis, which significantly increases its effectiveness, allows to prevent the development of complications and increase of the diseases severity. One of the gene polymorphisms involved in the development of arterial hypertension and disorders of carbohydrate and lipid metabolism is the polymorphism of A1166C gene of type 1 angiotensin II receptor (AGTR1). To study its participation in carbohydrate and lipid metabolism disorders in patients with arterial hypertension and nonalcoholic fatty liver disease, 55 patients, of them carriers of CC, A/C and A/A genotypes, were examined. Polymorphism of the angiotensin II type 1 receptor gene was performed using polymerase chain reaction. Serum glucose content was determined by the glucose oxidase method, insulin concentration − by immune enzyme method. The biochemical study included establishing the level of total cholesterol, high, low and very low density lipoproteins, triglycerides. Anthropometric indices of waist and hip size, height, body mass index were determined. Analysis of carbohydrate metabolism parameters, depending on AGTR1 gene genotypes in patients with hypertension and NAFLD shows that the carriers of C/C genotype have more pronounced disorders of carbohydrate metabolism in the form of hyperinsulinemia and decreased tissue sensitivity to insulin, whereas the patients with A/C and A/A genotypes are more resistant to gluco−metabolic disorders. The obtained data suggest that the allele C is a pathologic variant of AGTR1 gene (A1166C) polymorphism. The constitutional data of the examined patients did not differ. Evaluation of lipid metabolism in patients did not show differences between the levels of total cholesterol, high, low and very low density cholesterol, depending on genotypes of AGTR1 gene (A1166C). However, the generation of triglycerides was higher in the carriers of the C/C genotype, indicating the development of hypertriglyceridemia. Thus, comorbidity of arterial hypertension and non−alcoholic fatty liver disease in carriers of C/C genotype causes more distinct disorders of carbohydrate and lipid metabolism in the form of hyperinsulinemia, reduction of tissue sensitivity to insulin and hypertriglyceridemia while patients with genotypes A/C and A/A possess greater resistance to glucose−metabolic disorders.
Key words: polymorphism of A1166C gene of type 1 angiotensin II receptor, arterial hypertension, nonalcoholic fatty liver disease, metabolic disorders.
V. T. Zaitsev Institute of General and Emergency Surgery, NAMS of Ukraine, Kharkiv

Kharkiv National Medical University, Ukraine
Features of feeding in surgical patients with severe dysphagia
30 - 35
The ultimate goal of the treatment of patients with severe dysphagia is returning the possibility of alimentary nutrition by natural way, which is achieved by reconstructive surgeries, which are possible only after the restoration of the trophological status, or by holding dilatation procedures or coughing (only in compensated patients). To restore the trophological status in hospitals, both parenteral and enteral nutrition is used with the possibility of its realization. The work analyzed the results of surgical treatment of patients with extended postoperative scar strictures of the esophagus, taking into account the type of therapeutic nutrition. All examined patients had a nutritional deficiency. In order to provide the adequate parenteral nutrition and surgical treatment to prevent postoperative complications, and in case of their occurrence −− reduction of their severity at all stages of inpatient treatment, the third generation fat emulsion «Nutriflex Omega» was used. The patients who were able to receive enteral nutrition via probe (including gastrostomy) and natural pathways were used prior to surgical intervention and in the postoperative period «Nutricomp» balanced nutrition. Given the severity of the course of this disease, the general condition of patients with severe malnutrition status due to the ability to provide them with adequate enteral and parenteral support, the following tactics (algorithm) of treatment was proposed. All patients with disorders of the nutritional status are subject to dilatation procedures. When the esophagus passage is restored for a certain period of time, the passage of food in a natural way is created. But in the future, these patients need repeated bouginage or balloon dilation, and then reconstructive−restorative operative treatment −− esophagoplasty, which ensures the passage of food in a natural way. With ineffectiveness of the courses of dilatation procedures and impossibility of their conducting the patients develop exhaustion with severe metabolic disorders, and sometimes even cachexia. Such patients are subject to two−stage surgical treatment: at the first stage gastrostomy is performed for the purpose of establishing enteral nutrition and improvement of the trophological status; on the second stage −− after the restoration of the trophological status, an operative intervention is performed in the volume of the esophagus resection, esophagoplasty and closure of the gastrostomy opening, which also provides restoration of the natural passage of food. For the period of treatment with surgical intervention, such patients developed complications. But in patients receiving both parenteral and enteral nutrition complications arose in 4,2 % of cases, in contrast to the patients with only enteral nutrition, in which this figure was 21,9 %, and patients with only parenteral nutrition, in which complications were observed in 25,0 % of cases. There are differences in the indicators of mortality: in patients who received parenteral and enteral nutrition at the same time, no lethal cases were observed, while in the other two groups it was 7,3 % in the presence of only enteral nutrition and 6,8 % with only parenteral. Taking into account the results of this study on the surgical treatment of patients with severe dysphagia, regardless of tactics and surgical intervention method, it is noted that simultaneous use of enteral and parenteral nutrition at all stages is the basis for obtaining better postoperative results in comparison with the separate application of enteral or parenteral nutrition.
Key words: enteral nutrition, parenteral nutrition, dysphagia, surgical treatment.
V. T. Zaitsev Institute of General and Emergency Surgery, NAMS of Ukraine, Kharkiv, Ukraine
Modern approaches to treatment of spontaneous esophageal rupture
35 - 37
Despite the use of a huge range of modern surgical methods for treating spontaneous esophageal rupture, this problem is still relevant, as it is a rare and very serious disease. According to a number of authors, there are 5 (3,1 %) cases of spontaneous rupture per 161 cases of the esophagus perforation of different etiology. The term «spontaneous esophagus rupture» means that the individuals who previously had no diseases of this organ. The aim of the work was to improve the diagnosis and results of treatment of patients with spontaneous rupture of the esophagus. The paper presents the analysis of the results of treatment of 5 patients with spontaneous rupture of the esophagus for the period from 2014 to 2017 at V. T. Zaitsev Institute of General and Urgent Surgery (NAMSU). Stenting of the esophagus was performed with a one−step application of Blackmore probe, which, according to X−ray study, completely blocked the flow of the contrast substance behind the esophagus. To prevent pressure ulcers, repeated deflation of balloons was performed daily. The treatment of patients with esophageal pleural fistula initiated restoration of the adequate enteral nutrition and effective drainage of the pleural cavity. The technique did not result in postoperative complications or deaths. Thus, careful history taking noting the episodes of multiple indomitable vomiting is necessary. The standards of examination of such patients should include X−ray contrast and endoscopic examination of the esophagus (with minimal air inflation) as a method of specifying the diagnosis. Complex surgical treatment of the esophagus injury can reduce the traumatic nature of the surgical intervention, reducing the time of the operation. In the course of treatment, the patients take the nutrition naturally (directly into the stomach through the esophagus, not through the stoma). In this regard, we reduced the rehabilitation time after the surgery, as well as the number of complications and the overall mortality in this group of patients.
Key words: esophagus, spontaneous rupture, external esophageal pleural fistula.
The State Institution Romodanov Neurosurgery Institute National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
Significance of neurovisualizing methods for optimizing surgical tactics in patients with multiple cervical spine hernias
38 - 42
The diagnosis and subsequent differential surgical treatment of neurological manifestations resulting from the lesions of the cervical spine in osteochondrosis is an extremely difficult task. The wide introduction of neuroimaging diagnostic techniques (digital spondylography, computed tomography, magnetic resonance imaging) has significantly expanded understanding of the mechanism of neurological disorders in spine pathology. To evaluate the capabilities of neuroimaging methods of diagnosis in optimizing the choice of surgical tactics for the treatment of patients with multiple hernias of the cervical spine we investigated 157. In addition to evaluating the neurological symptoms, the history of the disease, the age of the patient, digital spondylography (including functional tests) CT, MRI were mandatory, which allowed to measure the Tchaikovsky's index, assess the degree of the intervertebral disk degeneration and dehydration according to C. W. Phirmann et al., 2001. Based on evaluation of the results of neuroimaging findings, 79 patients underwent puncture laser microdiscectomy; open microdiscectomy with subsequent installation of the cage was carried out by 78 patients. The patients were activated in the first 24 hours after the surgery. The term of hospital stay after puncture laser microdiscectomy was 1 day, that of open microdiscectomy with subsequent cage installation was 3−4 days. Postoperative complications were not observed. According to the results of our study, no cases of pain syndrome or progress of neurological symptoms in the early postoperative period were noted. Thus, the diagnostic information obtained with digital spondylography, CT, MRI allows to substantiate the choice of surgical tactics in patients with multiple hernias of the cervical spine. Puncture laser microdiscectomy can be performed in patients with Tchaikovsky's index over 0,8. Tchaikovsky's index < 0,7, as well as the degree of V degeneration of the intervertebral disc according to W. Phirrmann are contraindications to its use. In such cases, preference should be given to open discectomy followed by spinal fusion.
Key words: digital spondylography, computerized tomography, magnetic resonance imaging, multiple cervical spine hernias.
Kharkiv National Medical University, Ukraine
Estimation of the effectiveness of extracorporeal fertilization after transfer of vitrified blastocysts in the natural cycle and with the use of hormone replacement therapy
42 - 46
At present the most effective method of infertility treatment is extracorporeal fertilization. To increase the treatment effectiveness it is important to achieve the transfer of the best quality embryo during the greatest endometrial susceptibility to implantation. In this regard, support of the luteal phase (LPh) should become an integral component of IVF programs. The aim of this work was to study the effectiveness of IVF after the transfer of vitrified blastocysts in a modified natural cycle and with the use of hormone replacement therapy (HRT). The study included 173 patients of the main group, which were performed in vitro fertilization due to infertility of various origin. Group 1 comprised 51 patients with transfer of vitrified embryos to the natural menstrual cycle (MC). All observed women were monitored the growth of follicles using ultrasonography. All the patients were performed ultrasound monitoring of the follicle growth. Transvaginal ultrasound was performed using V−K Medical device. Five days after the ovulation the embryos were transferred to the uterus. Given the presence of a yellow body in the ovary at the time of ovulation, support for the second phase of the MC was not carried out. Group 2 included 92 women, who were prescribed gonadotropin−releasing hormone agonist at a dose of 0.05 mg subcutaneously daily 10 days before menstruation. Endometrium preparation was carried out with estrogens (estradiol valerate 6 mg daily). When the thickness of the endometrium reached 8 mm, gonadotropin−releasing hormone agonist was discontinued. Two days later, to support the luteal phase, 90 mg progesterone gel was administered intravaginally bid 14 days. Group 3 included the patients with a modified natural menstrual cycle, who had not undergone embryo transfer before because of a high risk of severe hyperstimulation. In this group of patients, all embryos obtained were vitrified (Freeze−all). Heated embryos were transferred to the uterus on the 5th day after the ovulation onset. Support for the luteal phase in this group of women was carried out by daily intravaginal administration of 90 mg progesterone gel for 2 weeks. The obtained findings confirm that after the transfer of embryos into the uterine cavity during the first 2 weeks, the woman's organism reacts to the support of the luteal phase differently, however, even in the absence of HRT, restores the hormonal potential, tuned for implantation and further embryo development. The most effective is the IVF protocol, in which the transfer of verified blastocysts occurs in a modified natural MC with LPH support by daily intravaginal 90 mg progesterone gel administration for 2 weeks. Progesterone, administered vaginally, directly affects the uterus and endometrium and within a few hours the level of this hormone in the blood increases. The main reason for the negative effect of high levels of progesterone administered on the efficacy of IVF is the phenomenon of premature transformation of the endometrium. Failure to transfer fresh embryos in stimulated menstrual cycles gives a high opportunity for pregnancy after transfer of vitrified blastocysts in a modified natural MC without a risk to the patient's health.
Key words: extracorporeal fertilization, hormone replacement therapy, luteal phase support, vitrified blastocysts.
Kharkiv Regional Clinical Perinatal Center, Ukraine
Practical issues of diagnosis and treatment of endometrium hyperplastic processes
47 - 52
Endometrial hyperplastic processes are pathological thickening of the glandular and stromal component of the uterine mucosa (focal or diffuse) with a predominant lesion of the glandular structures. Three main types of endometrial hyperplastic processes have been distinguished: endometrial hyperplasia, endometrial polyps and atypical hyperplasia (adenomatosis). The main diagnostic methods for endometrial hyperplastic processes are transvaginal ultrasonography, hydrosonography, cytological examination of aspirates from the uterine cavity, hysteroscopy. The definitive method of the diagnosis is histological examination of the uterine mucosa scraping. Typically, therapy in women of different ages consists of the bleeding control, restoring menstrual function (at reproductive age) or, conversely, achieving menopause (at an older age). Anyway, basic treatment is reduced to the prevention of relapse of endometrial hyperplastic processes. The traditional method of treatment is hormonal therapy. The choice of the hormonal medicine, the scheme and duration of its administration depend on the morphological structure of the endometrium, woman's age. The hysteroscopic ablation (resection) of the endometrium, hysterectomy are conducted according to the indications. Hysteroscopic ablation (resection) of the endometrium, hysterectomy are performed if indicated. All patients with endometrial hyperplastic processes should be followed up.
Key words: endometrial hyperplasia, endometrial polyp, hormonal therapy, hysteroscopy, endometrium ablation, hysterectomy.
S. P. Grigoriev Institute for Medical Radiology (NAMS of Ukraine), Kharkiv, Ukraine

Regional center of oncology, Kharkiv, Ukraine
Nutritional insufficiency in patients with gastrointestinal malignancies
53 - 56
Cancer is characterized by intoxication and disorders of all types of metabolism. Insufficiency of nutrition in cancer patients is noted in 80 % of cases, of them in 20 % it is the direct cause of death. The neoplasm location and the degree of protein−energy deficiency are related. The most frequent disorders of nutritional status are detected in patients with tumors of the gastrointestinal tract. In 2006, the Congress of the European Society for Enteral and Parenteral Nutrition (ESPEN) presented the data on the impact of nutritional support on the tumor growth. It was shown that weight loss leads not only to deterioration in the quality of life, but also to a higher mortality rate. The consensus group ESPEN−ESMO made a decision that in oncology, nutritional support is indicated as in no other field of clinical medicine and it has no effect on the tumor growth. With the development of nutritional insufficiency, there are syndromes of anorexia −− cachexia, hypermetabolism −− hypercatabolism, intestinal insufficiency syndrome. The overall goals of nutritional support in cancer patients are correction of protein−energy deficiency; maintenance of the visceral protein pool; minimization of side effects of radiation and chemotherapy; prevention and treatment of immunosuppression; improving the quality of life of the patients.
Key words: cancer of the gastrointestinal tract, nutritional deficiency, correction.
S. P. Grigoriev Institute for Medical Radiology (NAMS of Ukraine), Kharkiv, Ukraine
Epidemiology of leiomyoma, adenomyosis and uterine sarcoma (literature review)
57 - 61
The literature review contains modern data on the epidemiology of benign myometrium tumors −− leiomyomas and adenomyosis, which are among the most common diseases of the female genitals, as well as rare malignant non−epithelial tumors of the uterus −− sarcomas. Over the past decades, a marked increase in the incidence of benign and malignant tumors in the female sexual sphere has been observed. In Ukraine, in the context of birthrate reduction and a high level of overall mortality of the population, the problem of prevention, early diagnosis and effective treatment of such patients acquires special significance. To develop preventive measures, it is important to study the epidemiology of tumors of various locations. In the structure of female genital diseases, uterine leiomyoma ranks second after inflammation in this organ and its appendages, accounting for 15−20 % of cases. The results of epidemiological studies conducted in the world showed an increase in the frequency of detection of leiomyasis as the age of women increased. Numerous scientific sources report that there are differences in the frequency of the tumor detection, depending on the residence of women in different climatic and geographical areas; the tumors are more common in black people than the representatives of the white race. Differences in the incidence of leiomyoma detection among urban and rural populations have been described, in urban dwellers their rates are much higher. The patients with uterine leiomyoma have a high rate of surgical interventions −− up to 50−70 % of all operations performed in gynecological hospitals. The search for the ways to preserve the uterus in such patients is one of the most important tasks of modern gynecology and is based on the improvement of differential diagnosis of benign, borderline and malignant myometrial tumors even at the stage of examination, since it is the false suspicion of oncopathology that becomes an indication for unjustified operative interventions. Adenomyosis, or internal genital endometriosis, is a dyshormonal immune−dependent pathological process characterized by benign invasive growth of the endometrial glands in the muscular layer of the uterus and is accompanied by hyperplasia and hypertrophy of smooth muscle tissue. Adenomyosis is called a «missed» disease, because on an average interval between the moment of appearance of its first symptoms and before diagnosis is 7−8 years, which requires the timeliness and improvement of the quality of diagnosis of this pathology. At present, many researchers note an increase in the frequency of combined development of hyperplastic processes of endo− and myometrium, according to some data, from 63 to 73 % of cases, which is explained by common morphological, immunohistochemical features. Sarcoma of the uterus is more common in women aged 40−60. Similar deviations at this age are explained by changes in metabolic and hormonal processes, a decrease in local tissue resistance with the appearance of inferior connective tissue and atrophic phenomena in the genital organs. The risk factors for uterine sarcoma in pre− and postmenopausal women are uterine leiomyoma, especially fast−growing, late menarche, late first birth, multiple and spontaneous abortions, primary infertility, i.e. endocrine metabolic disorders manifested by hyperestrogenism. The theory that mutations of certain genes increase the likelihood of risk of sarcoma incidence has been features by a number of authors who say that retinoblastoma can have one genetic locus with leiomyosarcoma, and carcinosarcoma, being a hormone−dependent tumor, with carcinoma of the breast. Modern knowledge of the epidemiology of leiomyomas, adenomyosis and sarcomas in women of different ages and nationalities in the presence of certain risk factors will allow to develop a set of diagnostic and preventive measures for timely diagnosis and treatment tactics in the presence of this pathology and avoid unnecessary medical and surgical interventions.
Key words: epidemiology, leiomyoma, adenomyosis, uterine sarcoma.
Kharkiv Medical Academy of Postgraduate Education

City Clinical Hospital № 30, Kharkiv, Ukraine
Statistical analysis of diagnosis and treatment of serous otitis media in children
62 - 65
One of the pressing issues of pediatric otorhinolaryngology is secretory otitis media, a disease characterized by exudate accumulation in the middle ear cavities against a background of aseptic inflammation and the presence of grade 1−2 conductive hearing loss. Absence of pain syndrome in the clinical presentation of chronic otitis media, mild hearing impairment at early stages of the disease impede the diagnosis and timely treatment. The incidence of this disease was analyzed in children who were treated at KhMAPE hospital in 2013−2016. The effectiveness of the treatment algorithm was assessed; the ways to improve it (elimination of recurrence of the disease) were determined. When analyzing the statistical material, both an increase in the total quantity of acute otitis media over the years, and an increase in the number of cases stage 2 chronic otitis media with effusion, which required immediate full−fledged treatment (including surgical −− tympanopuncture, adenotomy under general anesthesia, if indicated) to prevent the transition of chronic otitis media with effusion to heavier forms, leading to adhesive processes in the tympanic cavity and formation of persistent hearing loss, were revealed. The children with recurrence of serous otitis media after performed adenotomy, tympanopuncture and a course of conservative treatment were determined to require an in−depth virological study of the nasopharynx. A more aggressive treatment tactics is used in patients with stage 2 disease: tympanopuncture of the tympanic membranes after confirmation of the diagnosis based on the disease history analysis, classical examination of the organs, impedance measurement, audiometry, endoscopy of the nose and nasopharynx. Expediency to study the persistence of Epstein−Barr virus in the nasopharynx and some immunity factors that undoubtedly affect the course of the disease is emphasized. The studies were carried out by the method of detection of antibodies to EBV using enzyme immunoassay (ELISA) in the blood serum. We consider that correction of these factors is the prospect of achieving a stable remission and recovery with complete restoration of auditory function in these children.
Key words: secretory otitis media, etiology, investigation, treatment.
Kharkiv Medical Academy of Postgraduate Education

City Clinical Hospital № 30, Kharkiv, Ukraine
The efficacy of elimination therapy in treatment of acute and chronic rhinosinusitis
66 - 71
The necessity to improve the methods of rhinosinusitis treatment and the role of the nasal mucosa microflora species in the pathogenesis and the effectiveness of treatment are shown. A comparative study of the effectiveness of lorect in elimination therapy of acute and chronic rhinosinusitis was performed. The dynamics of microbiocenoses and the degree of contamination of the mucous membrane of the nasal cavity on day 1−7 of treatment, the effect on the restoration of functional and objective indices (nasal breathing, excretory function, mucosa state), the degree of regression of manifestations of intoxication syndrome were studied. To assess the latter, a visual analogue scale was used. The dynamics of objective symptoms and functional indicators was assessed on a 4−point scale on days 1, 3, 5 and 9. It was revealed that with good tolerability and absence of side effects in patients, the use of lorect was accompanied by a reduction in the colonization of the mucous membrane of the nasal cavity with gram−negative flora and associations in favor of opportunistic and saprophyte microflora, against a background of reduction in the number of strains and the degree of microbial contamination. This positive dynamics of the mucosa sanation with lorect was accompanied by a significant improvement in the state of health and disappearance of subjective symptoms. The difference in the dynamics of objective indices in the main and control groups was shown on day 3 of treatment with lorect (reduction of hyperemia and edema of the mucosa, discharge from the nose, improvement of nasal breathing) with almost complete regression of symptoms and recovery of nasal breathing on day 6−7. Thus, the clinical effectiveness of the drug is based on its bactericidal effect on the pathogenic microflora, which contributes to a reduction in microbial contamination of the nasal mucosa, changes in the composition of microbiocenoses, and decrease in the pathogenicity of microorganisms. Its advantage is universality of the antimicrobial effect, including the gram−negative flora, resistant to the action of antibiotics and contributing to the development of intoxication syndrome, regardless of the form of sinusitis, the features of the course and sensitivity of microflora to antibiotics. The revealed high clinical efficacy of lorect gives grounds for recommending it for irrigation (elimination) therapy in acute and chronic bacterial rhinosinusitis, adenoiditis.
Key words: rhinosinusitis, adenoiditis, elimination therapy, microbiocenosis, lorect.
Heart Institute of the Ministry of Health of Ukraine, Kyiv

Kharkiv National Medical University, Ukraine
Prognostic significance of myocardial damage markers in the perioperative period in patients with acute coronary syndrome at coronary artery bypass grafting
72 - 78
Interventions with artificial circulation in patients with acute coronary syndrome are inevitably accompanied by ischemic damage to the myocardium, which leads to the appearance of cardiospecific enzymes and other biologically active substances in the blood, which are used as markers reflecting the degree of myocardial damage and severity of acute heart failure. To study the effect of levosimendan in the perioperative period on the level of markers of myocardial damage, the patients with acute coronary syndrome, who underwent coronary artery bypass graft were investigated. Hemodynamic indices were compared in patients who were applied a local protocol of anesthesia an intensive therapy and those who were additionally treated with levosimendan according to the following scheme: before induction to anesthesia 10 ?g/kg for 10 min, then at 0.1 ?g/kg/min up to 8 hours following the operation. The study was carried out at the following stages: 1) before surgery; 2) after cardiopulmonary bypass; 3) transfer to the intensive care unit; 4) transfer from the intensive care unit. At these stages, in addition to parameters of intracardiac and central hemodynamics, the levels of such markers of myocardial damage as TnI, СРK −− MB and NT proBNP were fixed. Analysis of the relationship between the baseline levels of myocardial damage markers and hemodynamic parameters at the end of the study suggests that elevated concentrations of the studied markers of myocardial damage allow to expect slowdown in the recovery of pumping function of the heart. That is, they can be considered as prognostic criteria. Although levosimendan optimizes the process of restoring blood circulation, it is impossible to control the initial disturbances completely with its help. In this case, TnI and СРK−MB can be called integral predictors of postoperative heart failure, since they are associated with СI, and the level of NT−proBNP primarily affects the ability of the myocardium to obey the Frank−Starling law. Our findings suggest that the levels of TnI, СРK−MB and NT−proBNP reflect the severity of heart failure and can be used as criteria for predicting the course of the early postoperative period. Levosimendan reduces the likelihood of exacerbation of both the initial and post−perfusion ischemic myocardial damage at acute coronary syndrome in patients undergoing coronary artery bypass graft.
Key words: levosimendan, myocardial damage markers, acute coronary syndrome, coronary artery bypass grafting, cardiopulmonary bypass.
Kharkiv National Medical University

Prof. O. I. Meschaninov Kharkiv City Clinical Hospital of Emergency Medical Care, Ukraine
Blood biochemical stress markers in patients with severe traumatic brain injury
79 - 82
According to the WHO, 10 million people in the world receive traumatic brain injury annually, of them 250−300 die. In Europe traumatic brain injury is the main cause of death among people under 35. During the acute period of traumatic brain injury, numerous mediators of systemic inflammatory response, which are both causative factors of the systemic inflammatory response and its markers, are formed in the organism. To study the biochemical markers of stress in the blood of patients with severe traumatic brain injury we investigated 40 patients with isolated severe traumatic brain injury on days 1, 3, 5 and 7 after the surgery. At these stages, the levels of insulin, cortisol, glucose in serum were studied, the HOMA index was calculated, and the period of recovery of consciousness and duration of artificial ventilation of the lungs was determined. On day 1 after the operation, the highest tension in stress reactions in patients was observed. It was confirmed by the maximum level of all stress markers. On day 3 stress reactions weakened, only glycemia did not have significant differences during the study, but a significantly higher level of insulin showed a high tension in the regulation of carbohydrate metabolism. Only day 7 of the study there was a significant decrease in these stress markers. In patients, the average duration of artificial ventilation of the lungs was 6,6±1,9 days, and consciousness during the study recovered by 3,7 points. Correlation analysis between the initial levels of stress markers and the duration of artificial ventilation of the lungs demonstrated that the initial tension of stress reactions affected the duration of artificial ventilation of the lungs and, consequently, the rate of recovery of consciousness. The level of cortisol had the greatest effect in this regard. The tension of stress reactions in patients with severe traumatic brain injury causes a significant increase of biochemical stress markers (cortisol, insulin, glucose} in the organism of patients, and their significant decrease occurs only on day 7. The initial tension of stress reactions affects the duration of artificial ventilation of the lungs, therefore, there is a further need for the use of drugs that could faster decrease the tension of stress reactions and shorten the duration of artificial ventilation of the lungs.
Key words: severe traumatic brain injury, stress markers, artificial ventilation of the lungs, consciousness restoration.
Kharkiv Medical Academy of Postgraduate Education, Ukraine
The state of venous hemodynamics in acute hemispheric ischemic stroke
83 - 86
Cerebrovascular pathology is the most significant among neurological diseases. In its structure, the share of ischemic strokes accounts for up to 80 % of all cases of acute disorders of cerebral circulation. Qualitative and quantitative study of the cerebral blood flow can be done with transcranial duplex and triplex ultrasound scanning. In acute and chronic disorders of cerebral circulation, the venous system of the brain can be included in the pathological process primarily. Hemodynamics with early signs of cerebrovascular insufficiency is manifested by vasoconstrictive disorders, and in severe stages by decrease in pulsation and difficulty in venous outflow from the cranial cavity. If the outflow of blood is difficult, typical for venous stasis microcirculatory disturbances are noted. Long−term venous dyscirculation results in clinical symptoms, leading to a decline in performance and a deterioration in the quality of life of patients. The purpose of our research was to evaluate qualitative as well as quantitative data of venous hemodynamics in patients with acute hemispheric ischemic stroke according to the data of transcranial triplex scanning. The study of cerebral veins was performed with the help of energy and pulsed−wave Doppler modes. When using transcranial triplex scanning, both qualitative and quantitative analysis were performed. Speed parameters of venous blood flow were assessed as well as its phase. The following parameters of venous blood flow were studied: the frequency of visualization of deep cerebral veins as well as the peak of velocity of venous blood−flow. Venous blood flow parameters were compared: frequency of deep cerebral veins visualization, peak velocity in patients with acute hemispheric ischemic stroke, transient ischemic attack, and healthy people. The most frequently visualized veins were examined: vein of Galen, Rosenthal vein, deep medial cerebral and tentorial sinus. It was noted that the frequency of visualization of intracerebral veins on the side of the cerebral infarction increased significantly. There was a significant increase in the last maximum rate of blood flow in the cerebral veins. A direct relationship (r = 0,72) was established between the velocity indices of venous blood flow and severity of ischemic stroke. A significant increase was observed in the phase nature of the spectrum at triplex scanning. Since a significant increase in the peak velocity of venous blood flow in ischemic stroke is evident, a change in its systolic velocity in the main cerebral veins and venous sinuses may be an important criterion for early differential diagnosis of ischemic stroke and other acute disorders of cerebral circulation. Thus, it was found that in ischemic stroke, the frequency of visualization of cerebral veins increases, systolic blood flow velocity in the examined veins increases simultaneously with reduction in the peak systolic velocity in the middle cerebral artery on the side of the stroke.
Key words: transcranial triplex scanning, ischemic stroke, state of venous hemodynamics.
Prof. M. I. Sytenko Institute of Spine and Joint Pathology, NAMS of Ukraine, Kharkiv, Ukraine
Ultrasonography of musculoskeletal and cartilaginous pathology in the shoulder joint region
87 - 91
At present it is assumed that pain in the humeroscapular area is usually a symptom of polyethiological origin. The variety of etiological factors and structural and functional manifestations of the pathological changes in the tissues of the humeroscapular area with minor differences in pain symptoms create significant difficulties in diagnosis without the use of special instrumental methods of investigation. The purpose of our work was to evaluate the capabilities of ultrasound (US) in differential diagnostics of pathological changes in articular and paraarticular tissues in the region of the shoulder joints, to identify the most characteristic ultrasonographic signs for various nosological forms of pain syndrome in this localization, basing on the own data analysis of ultrasonographic examination of the patients with humeroscapular pain syndrome (HSPS). The study involved 189 patients aged 18−75 years with complaints of pain and impaired function of the shoulder joint. The investigation was performed on the Siemens G−50 and Toshiba Aplio−500 ultrasound systems using a standard procedure. The analysis of the obtained results allowed to distribute the examined patients among 7 groups according to the nosological characteristics and to identify the most peculiar ultrasonographic criteria observed in different forms of HSPS. Group 1 included the patients with radiologically diagnosed osteochondrosis of the cervical spine. Group 2 included 12 patients whose X−ray examination showed the signs of osteochondrosis in the thoracic region. Group 3 included 57 patients with ultrasonographically demonstrated signs of inflammatory processes in the paraarticular tissues; thickening of the tendons of supraspinatus, infraspinatus, subscapular muscles and the tendon of long head of the biceps brachii muscles; degenerative changes, as erosions of the acromioclavicular joint contour, inflammatory changes and acromioclavicular ligaments edema; limitations of motor activity. Group 4 included the patients with ultrasonographically displayed inflammatory changes in the structure of supraspinatus tendon. The tendon was thickened, its echogenicity was reduced, its structure was inhomogeneous. In the structure, hyperechoic inclusions of various sizes (calcinates) were visualized. Group 5 included the patients with ultrasonographically demonstrated structural changes only in the acromioclavicular joint typical for osteoarthritis of the acromioclavicular joint. Group 6 consisted of female persons with tenosynovitis of the tendon of long head of the biceps brachii, significant thickening of the joint capsule, and subacromial conflict at abduction. Group 7 included the patients with complaints of pain and limitation of active movements in the shoulder joint, associated with traumatic damages or significant loads. Ultrasonography allows differentiation of the situations when the pain in the shoulder region can be related to pathological changes in the structure of the articular and paraarticular tissues of the shoulder joint from situations when it is not associated with such local processes but has a «reflected» character due to dystrophy of the cervical or thoracic spine.
Key words: ultrasonography, shoulder joint, humeroscapular pain syndrome.
Kharkiv National Medical University, Ukraine
Various aspects of obesity and overweight in children and adolescents
92 - 96
Increased prevalence of overweight children and adolescents in many countries makes it possible to classify this disease as a non−infectious epidemic. The most common complications of obesity are diabetes, arterial hypertension and digestive system diseases. To study and evaluate the impact of biological, social and hygienic, social and economic and psychological risk factors for children obesity a sociological survey was conducted in 809 children and adolescents aged 10 to 17 and their parents. Twenty−one factors with a significant effect on the development of the disease were distinguished. It was revealed that the leading risk factors for overweight were biological and social and hygienic. The main biological factors were family predisposition to overweight, type 2 diabetes mellitus and hypertension heredity. According to the study, the perinatal and postnatal factors have a significant impact on the onset and development of the disease in children, namely the pathological duration of pregnancy, complicated obstetrical anamnesis, the presence of excess body weight and the nutritional features of the child during the first year of life. Daily consumption of high−calorie foods, diet noncompliance and sedentary lifestyle were significant psychological and social and economic factors influencing the development of the disease. Socio− economic factors included the level of education of parents and the number of children in the family, while psychological −− stresses and psychological trauma. Priority preventive measures should be aimed at correcting the regimen, diet and optimizing the motor activity of children and adolescents.
Key words: obesity, excess body weight, risk factors, children and adolescents.
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