[The means of optimization of dispensary monitoring of patients in psycho-neurological dispensary].

The actual direction of improving provision of mental care of population is increasing of efficiency of specialized primary medical sanitary care of patients with mental disorders in conditions of implementation of biopsychosocial model of its realization. The study of mental disorders morbidity demonstrated that qualitative changes occurred in structure of contingents of mental institutions towards decreasing of number of dispensary patients and corresponding increasing of number of patients receiving medical and consultative assistance. The analysis of indicators of movement of contingents with mental disorders testifies decrease in effectiveness of dispensary observation that is confirmed by decrease of rate of de-registration due to recovery, by increase of de-registration due to death, increase in number of suicidal attempts and in disability among patients with mental illness of able-bodied age. It was established that problems in ensuring quality of medical care are conditioned manly by lack of actual organizational and methodological support of dispensary observation of patients, predominance of passive dynamic observation by local psychiatrist. Based on the results of study of organization of functioning of district psychiatrist, medical and organizational measures were developed to improve organization of dispensary observation of patients with mental disorders.

[The trends of spreading of tuberculosis combined with HIV-infection among population the Siberian Federal Okrug].

In The Russian Federation, the current epidemic situation of tuberculosis is characterized by stabilization and decreasing of morbidity with simultaneous increasing of number of cases of tuberculosis combined with HIV infection within the structure of newly diagnosed diseases and contingents of patients with tuberculosis. In the Siberian Federal Okrug, the indices of morbidity of tuberculosis combined with HIV infection exceed similar ones by almost twice that testifies significant input into burden of morbidity of tuberculosis in the subjects of the Siberian Federal District and their role in further dynamics of morbidity. The shift in morbidity of tuberculosis combined with HIV infection towards increasing of age both in patients with diagnosed HIV infection for the first time and in entire accumulated contingent of HIV patients. The positive dynamics of indices of efficiency of anti-tuberculosis measures in contingents of HIV-infected patients being registered testifies availability of reserves for improving medical care quality. The priority directions of developing program activities to achieve control over spreading of tuberculosis combined with HIV infection are early detection and increasing of commitment to dispensary observation of patients with HIV infection and decreasing infection of population with tuberculosis and increasing efficiency of treatment of patients with tuberculosis.

[The sociological aspects of organization of operation of district psychiatrists in modern conditions].

The article presents results of sociological survey of district psychiatrists that revealed actual difficulties and shortcomings in organization of medical care for mental patients. The problem of personnel high workload, inopportuneness and inadequate completeness of necessary medical care of mental patients are explained by a number of difficulties in organization of functioning of psychoneurological organizations. They included not only shortage of personnel and unsatisfactory material technical support of mental institutions, but also incompleteness of normative legal support mental care organization. The physicians identified the following priority targets to be implemented in practice will eliminate a number of actual problems in district psychiatrist work: organization of procedure of interdepartmental interaction of various services (GUFSIN, the Ministry of Internal Affairs, social protection agencies, passport office), development and approval of procedure of dispensary observation of mental patients, approval of procedure of interaction with territorial polyclinics and full implementation of medical care standards for patients with mental disorders. The administration of neuropsychiatric organizations from position of systemic approach is a priority direction of improving quality of medical care for mental patients.

Relationship between electrical myocardial instability and postinfarction remodeling in patients with ST-segment elevation myocardial infarction.

Aim      To study the clinical value of markers for myocardial electrical instability in combination with echocardiographic parameters for predicting the risk of cardiovascular complications (CVC) in the postinfarction period.Material and methods  This study included 118 patients with ST segment elevation myocardial infarction (STEMI) and hemodynamically significant stenosis of one coronary artery. A percutaneous coronary intervention (PCI) with stenting of the infarct-related artery was performed for all patients. On day 7-9 and at 24 and 48 weeks after the treatment, ECG Holter monitoring was performed, which included analyses of ventricular late potentials, dispersion of QT interval duration, heart rate turbulence (HRT) and variability (HRV), and heart chronotropic load (HCL). At baseline and during postinfarction week 12, all patients underwent echocardiography with calculation of indexes of end-diastolic volume (iEDV) and end-systolic volume (iESV) to verify the signs of left ventricular (LV) myocardial remodeling. The criteria for LV pathological remodeling included increases in iEDV >20 % and/or iESV >15 % at 12 weeks after STEMI. The group without remodeling, R(-), consisted of 79 (67 %) patients and the group with signs of LV pathological remodeling, R(+), consisted of 39 (33 %) patients. Quality of life and achieved endpoints were evaluated during 144 weeks.Results By week 48 in group R(-), the stabilization of electrical processes in the myocardium was more pronounced as indicated by a decrease in HFLA by 12 % (р=0.004) and by a fourfold increase in RMS (р=0.047). Only in this group, the baroreflex sensitivity restored; pathological ТРС decreased from 20 to 5% (p=0.002) by the end of the active treatment. Stabilization of the repolarization phase duration in various parts of the myocardium was more active in patients without pathological remodeling as shown by decreases in disp QTa (р=0.009), disp QTe (р=0.03), sd QTa (р=0.006), and sd QTe (р=0.009). This was not observed in the group R(+). The recovery of vagosympathetic balance due to leveling the sympathetic component also was more effective in the group R(-), which was reflected in increased spectral and temporal HRV indexes (р<0.05). Both groups showed reduced HCL values at 24 weeks (р=0.047 and р=0.006); however, the HCL regression remained also at 48 weeks only in the group R(-) (р=0.006). Group R(-) patients reported higher quality of life (р=0.03) than group R(+) patients. Endpoints were achieved more frequently in the group R(+): 87.1 % vs. 27.8 % (odds ratio, 11.8; 95 % confidence interval, 4.6-30.8; р=0.00001).Conclusion      Pathological myocardial remodeling in early postinfarction period is associated with electrophysiological instability of the myocardium, which results in the development of CVC and low quality of life in patients with STEMI.

[The effect of medical organizational factors on morbidity of mental and behavior disorders].

Currently, the characteristic of dynamics of morbidity of mental disorders of population of the Russian Federation is its increasing simultaneously with changing in structure of contingents in the direction of decreasing number of patients subjected to dispensary monitoring. The study of influence of medical organizational factors on morbidity of mental disorders demonstrated the role of provision with psychiatrists in dynamics of prevalence of mental disorders. The improvement of management of patients with mental disorders should be supported by appropriate resources and adaptation of mental service to actual conditions, in particular, solving the problem of manpower deficiency of psychiatrists.

Early Predictors of Heart Failure Progression in Patients After Myocardial Infarction.

Aim      To identify early predictors for progression of chronic heart failure (CHF) in patients with ST-segment elevation myocardial infarction (STEMI).Material and methods  The study included 113 patients with STEMI aged 52 (95 % confidence interval, 36 to 65) years. 24-h ECG monitoring was performed with assessment of ventricular late potentials, QT dispersion, heart rhythm turbulence (HRT), and heart rhythm variability (HRV); XStrain 2D echocardiograpy with determination of volumetric parameters, myocardial strain characteristics and velocities; and measurement of brain natriuretic peptide (BNP) concentrations. The endpoint was CHF progression during 48 weeks of follow-up, which was observed in 26 (23 %) patients. Based on the outcome, two groups were isolated, with CHF progression (Prg) (26(23%)) and with a relatively stable CHF postinfarction course (Stb) (87 (77 %)).Results At 12 weeks following MI, the Prg group showed increases in left ventricular (LV) end-diastolic dimension (EDD) (р<0.05) and end-diastolic and end-systolic volumes (EDV, ESV), (р<0.01), and EDV and ESV indexes (EDVi and ESVi, р<0.01). In this group, global longitudinal strain (GLS) was decreased at 24 weeks (р<0.05) and global radial strain (GRS) was decreased at 48 weeks (р=0.0003). In the Prg group, values of strain parameters (GLS, global circular strain (GCS), and GRS) were lower at all times. At 7-9 days, 24 weeks, and 48 weeks, the proportion of patients with pathological HRT was higher in the Prg group (38, 27, and 19 % for the Prg group vs 14 % (р=0.006); 3,4 % (р=0.001), and 2.3 % (р=0.002) for the Stb group, respectively). Only in the Stb group, increases in HRV were observed (SDNNi by 13 % (р=0.001), rMSSD by 24 % (р=0.0002), TotP by 49 % (р=0.00002), VLfP by 23 % (р=0.003), LfP by 22 % (р=0.008), and HfP by 77 % (р=0.002). At 7-9 days of MI, the Stb group had greater values of SDANN (р=0.013) and HfP (р=0.01). CHF progression correlated with abnormal values of turbulence onset (TO), disturbed HRT, increased BNP levels and LV ESD, and low values of GLS, GCS, and GRS. Combined assessment of HRT, LV ESD, and GLS at 7-9 days after STEMI allows identifying patients with high risk for CHF progression in the next 48 weeks.Conclusion      The markers for CHF progression after STEMI include abnormal TO values, disturbed HRT, increased BNP levels and LV ESD, and low values of GLS, GCS, and GRS. The multifactor logistic regression analysis revealed early predictors of CHF in the postinfarction period, including abnormal TO, increased LV ESD, and reduced GLS.

[On the issue of work time measurement in phthisiatricians rendering ambulatory polyclinic care to adult and children population].

The formation of the number of medical personnel, the establishment of labor standards, the rational distribution and use of personnel are the most significant components of the system of labor rationing in health care. Standard norms of working time for TB doctors are not developed. There is an uneven workload and a plan implementation indicator in different offices and cabinets. The timing of the working process of phthisiatricians providing outpatient care to adults and children was carried out; work time was spent on individual elements of the labor process of district phthisiatricians accepting adults and children and a phthisiatrician without district work receiving patients in the office tuberculosis care for HIV patients. The concept of "visitation" is defined as applied to the working conditions of the TB service. According to the results of time-keeping observations, technological operations performed by TB doctors, including additional sections of work that are not related to the admission of patients, are highlighted; the normative indicator of the function of the medical post of the district TB specialist and the normative indicator of the time spent on one visit are determined.

[The Impact of Effective Therapy With Atorvastatin on the Dynamics of Parameters of Electrical Instability in Patients with ST-Elevation Myocardial Infarction].

AIM: To assess the dynamics of parameters of myocardial electrical instability in patients with ST-elevation (STE) myocardial infarction (MI) treated with various doses of atorvastatin. MATERIALS AND METHODS: Patients with STEMI (n=70), who received atorvastatin 20 or 80 mg/day for 48 weeks, were divided into two groups: group "Е" - 38 patients (54.3 %) in whom by 48­th week target values of low density lipoprotein cholesterol (LDLC) were achieved, and group "NE" - 32 patients (45.7 %) in whom these levels were not achieved. On days 7-9, at 24th and 48th weeks after onset of MI the patients underwent 24­hour 12­leads ECG monitoring with subsequent analysis of parameters of myocardial electrical inhomogeneity: late ventricular potentials (LVP), dispersion of QT-interval duration, heart rate variability (HRV) and turbulence. RESULTS: After of treatment with atorvastatin target value of LDLC was achieved in 73.5 and 36.1 % of patients receiving 80 and 20 mg/day, respectively. In the group "E" we observed positive dynamics of LVP parameters (QRSf - p.

[The Sociological Aspects of Development of Organization and Enhancement of Quality of Hospital Medical Care of Patients with Tuberculosis].

The specially developed questionnaire on studying opinions of physician-phthisiatrician concerning hospital medical care of patients with tuberculosis was applied to survey sampling of 58 physicians phthisiatricians. The questions of questionnaire related to analysis of efficiency of hospital treatment of patients with tuberculosis, satisfaction with consultative and diagnostic activities, support with pharmaceuticals, discovering measures permitting to increase commitment of patients to treatment in conditions of hospital.

[THE EVALUATION OF EFFECTIVENESS OF FUNCTIONING OF TUBERCULOSIS HOSPITALS AND CALCULATION OF NECESSARY NUMBER OF BEDS AT THE REGIONAL LEVEL].

The adequate planning of capacity of hospital medical care accounting regional characteristics of prevalence of tuberculosis infection and functioning of anti-tuberculosis institutions are one of activities increasing effectiveness of resources using. So far, in the Russian Federation no techniques was developed permitting to determine need of tuberculosis service of region in number of beds based on epidemiological indicators of tuberculosis. To bring nearer as much as possible to reliable level of such a need in the Irkutskaia oblast the technique was developed on the basis of listing of indications for hospitalization of tuberculosis patients. This technique permits to substantiate the need of the subject of the Russian Federation in necessary number of beds in consideration of regional characteristics of prevalence of tuberculosis. This approach supports development of organization, planning and increasing of effectiveness of anti-tuberculosis activities in modern conditions.