[Possibilities for the improvement of the quality of knowledge and their evaluation in the course of studying clinical medicine].

The authors consider objective and subjective factors exerting negative influence on the quality of knowledge of physicians. The generally accepted methods for its evaluation (testing and rating-systems) have limitations. Testing reflects the level of knowledge with respect to the mode of thinking of its designer while rating mostly characterizes diligence of the trainee. It is proposed to improve the quality of knowledge by teaching the theory of diagnostics and to evaluate the amount of knowledge from the contents of the descriptive part of the medical history. The quality of knowledge can be assessed based on the contents of professional comments on the clinical picture described in the model case history.

[The functional properties and oxidative modification of plasma and neutrophil proteins in community-acquired pneumonia].

The functional properties of neutrophils (the activity of myeloperoxidase and the production of hydroxyl radical) were studied in community-acquired pneumonia (CAP) predominantly with the alveolar and interstitial types of lung parenchymal infiltration. Protein oxidative modification was estimated from the content of protein carbonyl derivatives in neutrophilic leukocytes and plasma and from the plasma concentration of bityrosine and oxidized tryptophan in patients with CAP. The production of hydroxyl radical and the activity of myeloperoxidase in the neutrophils of patients with CAP were increased and did not depend on the type of lung tissue infiltration. The development of oxidative stress in CAP was accompanied by the substantiation activation of protein oxidative modification processes in the neutrophilic leukocytes and plasma.

Role of thiol-disulfide system in mechanisms of functional changes in neutrophils under conditions of oxidative stress.

We studied the state of the thiol-disulfide system (contents of reduced and oxidized glutathione, their ratio, and concentrations of protein SH-groups and protein-bound glutathione) and functional properties of neutrophils (production of hydroxyl radicals, IL-8, and TNF-α and myeloperoxidase activity) from healthy donors under conditions of oxidative stress in vitro induced by H(2)O(2)in a final concentration of 200 µM and from patients with community-acquired pneumonia. We evaluated the role of reduced and protein-bound glutathione in the regulation of functional state of blood neutrophils from patients with community-acquired pneumonia and during oxidative stress in vitro under conditions cell incubation with N-ethylmaleimide or 1,4-dithioerythritolsulfhydryl, the blocker and protector of sulfhydryl groups, respectively.

[Total non-elastic pulmonary resistance and permeability of the alveolar capillary membrane in community-acquired pneumonia].

AIM: To study alveolar capillary membrane permeability (ACMP) and total non-elastic pulmonary resistance (TNPR) in patients with community-acquired pneumonia (CAP) in an acute period. MATERIAL AND METHODS: ACMP of the lungs was studied in 35 CAP patients with ventilation pulmonoscintigraphy. Integral and regional TNPR were registered at inhalation and expiration. Integral TNPR was estimated by simultaneous registration of transpulmonal pressure and spirogram, regional TNPR (in the upper, middle and lower zones of the lungs)--by simultaneous registration of zonal rheograms of ventilation and transpulmonal pressure. Bronchial resistance was measured by body plethismograph (Masterlab pro, Erich Jaeger, Germany). RESULTS: In acute CAP integral TNPR rose while regional values varied. Both integral and regional ACMP for affected and intact lungs were significantly elevated showing systemic impairment of the structures of alveolar-capillary membrane of the lungs. More severe alterations of integral ACMP were seen in the affected lung, of regional--in the affected zones. CONCLUSION: Changes registered in regional TNPR and ACMP may indicate enhanced mechanical activity of the lungs in these zones. This enhanced activity contributes to TNPR overcoming.

[Extrahospital pneumonias: the clinico-scintigraphic characterization and oxidative balance of cells].

Ventilation-perfusion pulmonary scintigraphy was carried out in 30 patients with a verified diagnosis of extra-hospital pneumonia (EHP) and 10 healthy subjects; ventilation-perfusion ratio (V/Q), apex-basis ventilation and perfusion gradient, and the condition of alveolar-capillary permeability (ACP) were analyzed. Clinical symptoms during the debut of EHP were more pronounced in patients with an alveolar type of pulmonary infiltrate (PI) vs. patients with interstitial one: they had pulmonary infiltration syndrome, pleural pain, tachypnoe, tachycardia, a fever of higher than 38 degrees C, and leucocytosis more often. During the acute period of EHP, elevated lipid peroxidation in the erythrocyte membrane as well as a decrease in the content of reduced glutathione and the activity of superoxide dismutase and catalase in erythrocytes did not depend on the type of PI. In EHP, independently of PI type, the study revealed an increase in V/Q of higher than 1.0 on the side of lesion and bilateral (including the healthy side) increase in ACP for radioactive aerosol.

[Possibilities of overcoming difficulties in the differential diagnosis of nonmassive pulmonary thromboembolism in patients taken to the hospital by ambulance].

AIM: To optimize the differential diagnosis of nonmassive pulmonary thromboembolism (PTE) in patients emergently admitted to a multidisciplinary hospital. MATERIALS AND METHODS: The study enrolled 36 patients with nonmassive PTE and 28 with community-acquired pneumonias (ACP). All the patients underwent a comprehensive study, including primarily a clinical study in order to search for the early clinical manifestations of PTE. Ventilation-perfusion lung scintigraphy (VPLS) was performed in 11 patients with nonmassive PTE, 28 with ACP, and 10 healthy volunteers. RESULTS: The initial diagnosis of ACP was established in 26 of the 36 emergently hospitalized patients. Most early clinical manifestations of PTE and A CP were similar; their distinguishing features suggested that there might be nonmassive PTE. It is suggested that VPLS should be used for differential diagnosis in the above cases, by additionally assessing alveolar-capillary permeability. Twenty-eight patients with ACP were found to have a pronounced and significant acceleration of alveolar-capillary permeability in the affected lung at minutes 10 [23.5 +/- 1.9% (versus 8.02 +/- 3.89% in 11 patients with nonmassive PTE; p = 0.01)] and 30 of the study [33.4 +/- 1.9% (versus 13.64 +/- 4.0% in nonmassive PTE; p = 0.004)] while in nonmassive PTE, alveolar-capillary permeability corresponded to the values typical of healthy individuals, without exceeding 12 and 22% at minutes 10 and 30 of the study, respectively. CONCLUSION: VPLS makes it possible to verify or exclude the thromboembolic nature of pulmonary perfusion disorders. If it is difficult to make a diagnosis in the presence of the clinical symptoms characteristic of both nonmassive PTE and ACE, VPLS with an additional assessment of alveolar-capillary permeability, ACP substantially increases the accuracy of differential diagnosis of nonmassive PTE and ACE.

[Bronchial capacity in community-acquired pneumonia].

AIM: To examine bronchial capacity (BC) in patients with community pneumonia (CP) by speed characteristics of pulmonary ventilation function (PVF) and bronchial resistance (Raw). MATERIAL AND METHODS: Monitoring of a peak expiration speed (PES) was made in 99 CP patients. In addition, 46 of them have undergone spirometry and bodyplethysmography (Masterlab pro device) with measurement of airflow speed, Raw and structure of total lung capacity. RESULTS: In 88.9% patients with CP the initial PES was subnormal but its normalization occurred (in 79.7%) within 3 days of stable normalization of body temperature. This was confirmed by a strong negative correlation between the initial PES and body temperature in admission of CP patients to hospital (r = -0.73, p = 0.001). Raw in 86.9% patients with CP is normal (74.53 +/- 4.50%) both in moderate and acute fall of PVF speed characteristics. If these characteristics in CP patients are low, Raw should be examined. High Raw in this case justifies the diagnosis of latent chronic obstructive pulmonary disease. CONCLUSION: Raw in 86.9% CP patients is normal, thus indicating no impairment of bronchial capacity. Obstructive disorder of lung ventilation in acute CP detected at spirometry is explained by non-pulmonary causes. For diagnosis of BC affection in patients with CP and low speed characteristics of PVF, bronchial resistance must be examined. High bronchial resistance in such cases indicates latent chronic obstructive pulmonary disease.

[Ventilation-perfusion pulmonary scintigraphy for diagnosis of pulmonary thromboembolism].

Ventilation-perfusion pulmonary scintigraphy with analysis ofventilation-perfusion ratio, apex-base ventilation and perfusion gradient, pulmonary perfusion, and the condition of alveolar permeability at the 10th and 30th min after inhalation of radiopharmaceutical was carried out in 16 patients with clinical and scintigraphic signs of thromboembolism of distal pulmonary artery branches and 10 controls. Thromboembolism of distal pulmonary artery branches was manifested by an increase in apex-base ventilation and perfusion gradient in both involved and intact lungs vs. the same parameters in healthy people. Patients with bilateral thromboembolism of distal pulmonary artery branches were characterized by an increase in ventilation-perfusion ratio and retardation of alveolar permeability.

[The structural-functional properties of the erythrocyte membranes in patients with ischemic stroke and circulatory encephalopathy]. / Strukturno-funktsional'nye svoistva éritrotsitarnykh membran u bol'nykh s ishemicheskim insul'tom i distsirkuliatornoi éntsefalopatiei.

68 patients with cerebrovascular disorders (37 cases of ischemic stroke and 31 cases of dyscirculatory encephalopathy) were examined for microhemorheology (erythrocytic form and deformability); fractional composition of neutral lipids; blood phospholipids; those in red cells and their membrane environment (ME); erythrocytic sorption capacity in plasma and ME by fibrinogen. Neutral lipids were found to undergo metabolic disorders manifested as lowered amount of phospholipids, elevated levels of free fatty acids, triglycerides and cholesterol ethers. The fractional composition shifted to a growing toxic fraction of lysophosphatides and reducing fraction of phosphatydilcholine. The changes were of the same type in all the tested media and seemed interrelated. Along with alterations in the membrane lipid composition there appeared functional changes in erythrocytes: deformability decreased, echinocytes emerged, membrane sorption capacity enhanced, ME fibrinogen rose.

[Haemophilus infection in nonspecific inflammatory lung diseases]. / Gemofil'naia infektsiia pri nespetsificheskikh vospalitel'nykh zabolevaniiakh legkikh.

Hemophilic infection incidence rate, characteristics and criteria of early detection were studied in 393 patients with nonspecific pulmonary diseases. H. influenzae represented the prevalent pathogenic agent in 17% of the cases: in 11% of acute pneumonias (276 patients) and 30% of chronic bronchitis exacerbations (117 patients). Hemophilic pneumonias were a more frequent finding in patients over 40 years of age, proved secondary, manifested usually interstitial inflammation of the lung tissue, were prone to interlobitis complication and protracted course. Purulent endobronchial inflammation used to be a typical sign of hemophilic aggravation of chronic bronchitis.

[Chart-algorithm of early etiological diagnosis of acute pneumonia]. / Skhema-algoritm rannego étiologicheskogo diagnoza ostroi pnevmonii.

A proposed method of scheme-algorithm is aimed at facilitation of an early etiological diagnosis of acute pneumonia (AP) by initial clinical signs. A blind trial with 78 AP verified cases showed that the scheme can establish a correct etiological diagnosis basing on AP early clinical symptoms alone in 75% of cases. The sensitivity of the method is 75%, specificity 91%.

[Criteria and methods of etiological diagnosis of acute and chronic inflammatory processes in the lungs]. / Kriterii i metody etiologicheskoi diagnostiki ostrykh i khronicheskikh vospalitel'nykh protsessov v legkikh.

The clinical, bacteriological, cytological, serological and allergological data were analyzed in 376 patients with acute pneumonia and chronic bronchitis to study the diagnostic importance of the microorganisms isolated from the sputum. The informativeness of the methods was estimated by correlation of the appropriate data with the data of the final verified diagnosis of the inflammatory process in the lungs. Bacterioscopy of the sputum smear stained according to Gram, bioassay on mice, determination of bacterial concentration per ml sputum, allergic tests with bacterial allergens were found to be the most reliable methods as regards the etiological diagnosis of acute pneumonias. It should be mentioned that bacterioscopy is an early criterion of the disease etiology. Criteria of the etiological significance of bacteria which cause exacerbation of chronic bronchitis encompass the measurement of bacterial concentration per ml sputum, indirect immunofluorescence with autostrains of the isolated bacteria and the bioassay. Early criteria include the first two methods.

[2-stage treatment of acute pneumonia patients with rehabilitation at the sanatorial stage]. / Dvukhétapnoe lechenie bol'nykh ostroi pnevmoniei s reabilitatsiei na sanatornom étape.

A total of 73 patients with acute pneumonia received two-stage treatment: etiotropic treatment based on early etiological diagnosis (at hospital) and subsequent early rehabilitation at sanatorium with the use of peloid therapy. It made it possible to attain the best short-term results in the treatment of pneumonias (as compared with control group patients), to shorten 2-4-fold the times of the patients' stay at hospital and to raise bed capacity, to reduce the total doses and duration of antibacterial therapy, to decrease the possibility of the allergic reactions and side effects, and to reduce 2-fold the cost of antibacterial therapy.