Co-morbidity of infectious and addictive diseases in St. Petersburg and the Leningrad Region, Russia.

The Russian health care system is organized around specific diseases, with relatively little focus on integration across specialties to address co-morbidities. This organizational structure presents new challenges in the context of the recent epidemics of injection drug use (IDU) and HIV. This paper uses existing and new data to examine the prevalence of reported new cases of drug dependence (heroin) and HIV over time as well as associations between drug dependence and alcoholism, hepatitis B and C, and tuberculosis in the City of St. Petersburg and the Leningrad region. We found a sharp rise in reported cases of IDU beginning in 1991 and continuing until 2002/2003, followed by a sharp rise in newly reported cases of HIV. These rises were followed by a drop in new cases of HIV and drug addiction in 2002/2003 and a drop in the proportion of HIV-positive individuals with IDU as a risk factor. Infection with hepatitis B and C were common, especially among injection drug users (38 and 85%, respectively), but also in alcoholics (7 and 14%). Tuberculosis was more common in alcoholics (53%) than in persons with alcoholism and drug dependence (10%), or with drug dependence alone (4%). Though these data have many limitations, they clearly demonstrate that drug dependence and/or alcoholism, HIV, hepatitis, and tuberculosis frequently co-occur in St. Petersburg and the Leningrad Region. Prevention and treatment services across medical specialties should be integrated to address the wide range of issues that are associated with these co-morbidities.

[Significance of tuberculosis of the large bronchi in the diagnosis and treatment of restrictive forms of pulmonary tuberculosis]. / Znachenie tuberkuleza krupnykh bronkhov v diagnostike i lechenii ogranichennykh form tuberkuleza legkikh.

A total of 1223 new cases of restrictive forms of pulmonary tuberculosis were examined. Of them 652 and 598 patients were followed up in the period of the good (1980-1984) and poor (1997-2001) tuberculosis epidemiological situation, respectively. A comparative analysis has indicated that there has been recently a rise in the incidence of tuberculosis of main bronchi from 10.5 to 18.0%, which most commonly complicates intrathoracic lymph nodal or infiltrative pulmonary tuberculosis. A more severe clinical course and a more frequent bacterial isolation have been ascertained mainly in infiltrative, ulcerative, and fistular forms of bronchial tuberculosis irrespective of the form of pulmonary tuberculosis. The comprehensive examination of patients with restrictive pulmonary tuberculosis is certain to include bronchial fibroscopy that may determine the form and phase of bronchial tuberculosis, the rate of a process in the lung, make and differentiate its diagnosis, use systematic and topical therapy (with hydrocortisone aerosols, GINK, streptomycin), and cure bronchial tuberculosis within 2-3 months.

[Post-tuberculous fibrous mediastinitis: a report of a case followed-up for many years]. / Posttuberkuleznyi fibroziruiushchii mediastinit (analiz mnogoletnego nabliudeniia).

The paper reports a rare case of fibrosing mediastinitis of posttuberculous genesis caused by infection with Mycobacterium bovis. Such cases are not available in the literature so far. The patient was observed from 1956 to 2001. Bovine tubercle bacilla affect mediastinal lymph nodes which undergo fibrosis resulting in stenosis of the trachea, major bronchi, esophagus. Narrowing of the chest duct leads to formation of severe recurrent transudate in the left pleural cavity (for 3 years 70 pleural punctures were made with removal of a total of 22 l of fluid).

[The body's adaptation and responsiveness and their impact on the outcome of exudative pleuritis]. / Adaptatsiia, reaktivnost' organizma i ikh vliianie na iskhod éksudativnogo plevrita.

The authors studied homeostasis in 182 patients, including 126 patients with exudative pleuritis of tuberculous etiology and 56 with parapneumonic pleuritis. They determined the adaptive reactions of the body by the leukograms and the types of its responsiveness, established their relationship with other homeostatic parameters. Impaired responsiveness in patients with exudative pleuritis substantially affected the efficiency of etiotropic treatment. At the end of the basic course of therapy, the rate of marked residual pleural changes was 84.6% in patients with tuberculous pleuritis (Subgroup 1). Activation pathogenetic therapy with methyluracil promoted a reduction in the number of patients with significant residual pleural changes (32.8% in Subgroup 2).

[Stage I-III pulmonary sarcoidosis complicated by nephrogenic (vasopressin-resistant) form of diabetes insipidus]. / Sarkoidoz lëgkikh III stadii, oslozhnennyi nefrogennoi (vazopressin-rezistentnoi) formoi nesakharnogo diabeta.

Literature data and original experience of the authors with 6890 cases of respiratory sarcoidosis (stage I-III) suggest that diabetes ipsipidus in respiratory sarcoidosis (RS) can present as hypothalamic-hypophysial form (observed at the stage I-II by physicians since 1935) and a new form--nephrogenic (vasopressin-resistant) at stage II of pulmonary sarcoidosis. The latter form is little known. It was found that in stage III sarcoidosis patients who have severe fibrosis of the lungs and a long history of corticosteroid hormone treatment the nephrogenic form of the pathogenesis is caused by defects in calcium metabolism leading to nephrocalcinosis with low sensitivity of renal tubular receptors to ADH. Adiurecrine treatment is unefficient. It is recommended to use chlorpropamide which raises sensitivity of the tubules to ADH.

[Clinical and immunological characteristics and specific features of the treatment of patients with recurrent sarcoidosis of respiratory organs]. / Kliniko-immunologicheskaia kharakteristika i osobennosti lecheniia bol'nykh s retsidiviruiushchimi formami sarkoidoza organov dykhaniia.

In the past 35 years, the authors have followed up 5600 patients with sarcoidosis of respiratory organs (SRO), among whom 1.2 and 10.7% were found to have single and multiple recurrences. The clinical manifestations of recurrent sarcoidosis were moderate, by showing a drastic reduction in the count of T and T"a" lymphocytes, as well as helper lymphocytes, and an increase of circulating immune complexes and immunoglobulins G, A, and M. Poor adaptive responses (AR) defined by the blood leukocyte and lymphocyte counts that reflect the body's nonspecific responsiveness were concurrently diagnosed. In chronic recurrent SRO, poor AR as stress and superactivation amount to as much as 86.1%. To optimize treatment, the patients were given adaptogens (thymaline, levamisole, dibasole, etc.) that make AR better, by enhancing the efficiency of treatment, reducing its duration, and improving prognosis.

[Diagnostic features of focal pulmonary tuberculosis in new cases]. / Osobennosti diagnostiki ochagovogo tuberkuleza legkikh u vpervye vyiavlennykh bol'nykh.

The authors examined 120 new cases of focal pulmonary tuberculosis (FPT) during the good epidemic situation years (1982-1986) and 70 patients during the poor epidemic situation years (1995-1999). The latter years were marked by a worse social composition, more frequent contacts with those isolating bacteria, a more severe course with weight loss, prolonged subfebrile temperatures, anemia, an increasing tendency for lung tissue decay and even in large foci, a more frequent bacterial isolation along with progressive immunodeficiency. New diagnostic technologies, such as computed tomography, T-lymphocytic studies at the subpopulational level by using monoclonal narrow-specific antibodies, adaptive response tests that reflect the body's responsiveness, are of value in diagnosing FPT.

[Causes of fatal outcomes in patients with sarcoidosis]. / Prichiny letal'nykh iskhodov u bol'nykh sarkoidozom.

There have been 21 (7.4) fatal cases among 282 patients with diffuse sarcoidosis of the lung and other organs in the past 30 years. The study of the causes of death indicated that 5 patients had progressive sarcoidosis of the lung and intrathoracic lymph nodes with progressive cardiopulmonary failure. Ten other dead persons had generalized generalized sarcoidosis; sarcoidosis of the central nervous system, liver, spleen, and kidney with marked progressive failure of these organs were of the greatest contribution to death. Concomitant diseases, such as pyoinfection, bronchiectasis with pulmonary hemorrhage, essential hypertension, diabetes, and bronchial cancer, are causes of death in 5 more patients with pulmonary sarcoidosis.

[Assessment of homeostasis by body's adaptative responses in patients with tuberculous pleurisy]. / Otsenka gomeostaza po adaptatsionnym reaktsiiam organizma u bol'nykh tuberkuleznym plevritom.

The types of adaptative responses were defined, by analysing leukograms in 126 patients with tuberculous pleurisy. Assessing homeostasis by proteinograms, cellular and humoral immunity verified adaptative responses as an integral index of responsiveness. This identified 5 types of responsiveness. Abnormal (hyperactive, hyporeactive, paradoxical, and areactive) responsiveness was found in 78.6% of patients with tuberculous pleurisy. All outcomes with significant residual pleural changes were observed in patients with abnormal responsiveness. Adaptative responses may be used in the clinical setting not only for evaluation of homeostasis, but for prediction of prognosis and for organization of controlled pathogenetic therapy on an individual basis.

[Specific features of diagnosis and treatment of patients with pulmonary sarcoidosis and tuberculosis]. / Osobennosti diagnostiki i lecheniia bol'nykh sarkoidozom v sochetanii s tuberkulezom organov dykhaniia.

In the past 30 years, the authors examined and treated 6473 patients with pulmonary sarcoidosis, of them 105 (1.6%) had contacted with the individuals isolating Mycobacterium tuberculosis and 45 (0.7%) had a history of various forms of pulmonary tuberculosis; however, the patients with pulmonary sarcoidosis had neither exacerbations nor relapses. Of the 6473 patients, 41 (0.63%) was diagnosed as having active pulmonary tuberculosis, including 20 with focal pulmonary tuberculosis, 13 with disseminated pulmonary tuberculosis, 4 pulmonary tuberculosis with infiltrative, and other 4 with destructive pulmonary tuberculosis, disseminated and destructive pulmonary tuberculosis occurred in the progressive pulmonary sarcoidosis. The etiopathogenetic treatment of tuberculosis with at least 3-4 drugs (small-dose hormones, antioxidants, immunomodulators) was found to cure the two abnormalities in 95.2% and in 4.8% of cases, the pathological process became chronic when limited disseminated pulmonary tuberculosis was concurrent with disseminated pulmonary sarcoidosis.

[The differential diagnostic characteristics of sarcoidosis of the intrathoracic lymph nodes and of cardiovascular diseases]. / Osobennosti differentsial'noi diagnostiki sarkoidoza vnutrigrudnykh limfaticheskikh uzlov i nekotorykh serdechno-sosudistykh zabolevanii.

One hundred and fifty-four (5.7%) of 2690 patients who had been admitted to a hospital for sarcoidosis of intrathoracic lymph nodes (ITLN) were diagnosed as having various cardiovascular diseases (hypertensive disease, congestive lung, congenital and acquired cardiac diseases, atherosclerosis, aortic aneurysms and myocarditis). Misinterpretation of the X-ray film of the lung root, no lateral X-ray films, inadequate scope of objective studies of the cardiovascular system are the most common errors at prehospital examination. The obligatory making of lateral X-ray films, tomograms, the use of computed tomography, ECG and phonocardiography, and thorough account of objective data are valuable additional methods in the differential diagnosis of ITLN sarcoidosis and cardiovascular diseases accompanied by the appearance of wide truncal large vessels of the root due to pulmonary hypertension.

[Long-term follow-up of patients with sarcoidosis of respiratory organs]. / Otdalennye rezul'taty nabliudeniia za lechenymi bol'nymi sarkoidozom organov dykhaniia.

Long-term (3-25 years) responses to treatment are available for 1820 patients with respiratory sarcoidosis. 65.7% of them were females and 34.3% males primarily at the age of 21-50 (92.7%). Sarcoidosis of the intrathoracic lymph nodes (ITLN), sarcoidosis of the lungs and ITLN, diffuse forms of pulmonary sarcoidosis, generalized sarcoidosis were diagnosed in 64, 28.2, 4.6, 2.6% of patients, respectively. All the patients received combined pathogenetic treatment (hormones, antioxidants, antihypoxants, immunomodulators, angio- and hepatoprotectors) which proved highly long-acting in stage I-II (a complete response rate 84.3% and 82.7%, respectively, residual changes remained in 1/5 of the patients). Long-term recurrences occurred in 3.5% of patients who had marked residual changes in the lungs. The disease took a chronic course in 8.7%, progression was recorded in 9.3, lethal outcome in 0.7% of the cases.