[New clinical guidelines for COPD - a paradigm shift: A review].

Chronic obstructive pulmonary disease is now one of the most common noncommunicable diseases and the main causes of morbidity, disability and mortality in the world. In recent years, new approaches to epidemiology, diagnosis, classification (categorization), evaluation of phenotypes, as well as characterization and assessment of the severity of сhronic obstructive pulmonary disease exacerbations have emerged. Modern approaches to starting and subsequent drug therapy have changed significantly. This is largely due to the results of recently conducted major clinical trials, demonstrated high efficacy of triple fixed combinations, including inhaled glucocorticosteroids, long-acting beta-agonists and long-acting anticholinergic drugs. The use of non-medication methods (smoking cessation, physical activity and respiratory rehabilitation) and modern approaches to the treatment of respiratory failure and antibiotic therapy remain important. In terms of their significance, all these updates have a significant impact on real clinical practice and can be considered as a novel paradigm of the approaches to the diagnosis and management of this disease.

[Respiratory disorders of post-COVID-19 syndrome].

AIM: Assess the functional state of trespiratory system and effectiveness of therapeutic tactics for broncho-obstructive syndrome (BOS) in patients in the post-COVID period. MATERIALS AND METHODS: A two-center cohort prospective study included 10 456 and 89 patients, respectively. A comprehensive assessment of the respiratory system included clinical, laboratory and functional data, spirometry, body plethysmography, and a study of diffusive capacity of the lungs (DLCO). Therapy consisted of budesonide suspension or fixed combination beclomethasone dipropionate/formoterol (EMD BDP/FORM). RESULTS: The frequency of BOS in the cohort was 72% (7497 patients). In 13% (n=974) of cases, bronchial asthma was diagnosed for the first time, in 4.4% (n=328) - chronic obstructive pulmonary disease. Risk factors for the development and decrease in DLCO in the post-COVID period were identified. In the group of complex instrumental examination of lung function, the absence of violations of spirometric data and indicators determined by body plethysmography was determined. CONCLUSION: Risk factors for BOS in post-COVID period are atopy, a history of frequent acute respiratory infections, smoking, blood eosinophilia, moderate and severe forms of COVID-19. The advantage of a fixed combination of EMD BDP/FORM in MART mode compared with nebulized suspension budesonide + solution of salbutamol in treatment of BOS was shown. Risk factors for DLCO disorders were established: severe COVID-19, hospitalization in the intensive care unit, the need for additional oxygen therapy.

[Evaluation of the efficacy and safety of a combination drug containing ambroxol, guaifenesin, and levosalbutamol versus a fixed-dose combination of bromhexine/guaifenesin/salbutamol in the treatment of productive cough in adult patients with acute bronchitis].

AIM: To evaluate the efficacy and safety of a combination drug containing ambroxol, guaifenesin, and levosalbutamol, oral solution, versus Ascoril Expectorant, syrup (combination of bromhexine, guaifenesin, and salbutamol) in the treatment of productive cough in adult patients with acute bronchitis. MATERIALS AND METHODS: This open-label, randomized, phase III study included patients with acute bronchitis who had a productive cough with difficulty in sputum expectoration. 244 patients were randomized in a 1:1 ratio and received 10 mL of the study drug or reference drug 3 times daily for 2 weeks. After 7 and 14 days of treatment, the physician evaluated patient's subjective complaints and the efficacy of therapy. The primary endpoint was the proportion of patients with high and very high efficacy. RESULTS: The primary endpoint was reached by 70 (0.5738) patients in the study drug group and 54 (0.4426) in the reference drug group (p=0.04). The intergroup difference was 0.1311 [95% confidence interval: 0.0057; 0.2566]. The lower limit of the 95% confidence interval was above zero, which confirms the superiority of therapy with the study drug over therapy with Ascoril Expectorant. The proportion of patients with a 1-point total score reduction and with complete resolution of all symptoms according to the Modified Cough Relief and Sputum Expectoration Questionnaire after 7 and 14 days was numerically higher in the study drug group versus the reference drug group. There were no statistically significant differences between the groups in the incidence of adverse events. CONCLUSION: The efficacy of a new combination drug containing ambroxol, guaifenesin, and levosalbutamol in the treatment of productive cough in adult patients with acute bronchitis is superior to the efficacy of Ascoril Expectorant. The safety profiles of the study drug and the reference drug were comparable.

[Problems and opportunities to improve diagnosis of asthma and chronic obstructive pulmonary disease in Russia: resolution of advisory board].

Asthma and chronic obstructive pulmonary disease remain major problems of medicine, and still there is need to improve the level and quality of diagnosis of these diseases. Primary care physicians (general practitioners, therapists) should be involved widely and actively in this process. To simplify the diagnosis, special questionnaires have been developed, they can be used in a real clinical practice. Only this approach will bring statistical data closer to the true prevalence of these diseases and improve quality of their treatment.

[CLINICAL AND PATHOLOGICAL ANALYSIS OF THE HYPOPLASTIC LEFT HEART SYNDROME IN ONE OF THE TWINS IN PREGNANCY WHICH OCCURRED USING IN VITRO FERTILIZATION. OWN OBSERVATION].

The article represents clinical and pathoanatomical analysis of a case of full-term pregnancy with hypoplastic left heart syndrome (HLHS) in one of the twins, which occurred using in vitro fertilization (IVF). The dead macerated fetus with malformations after selective feticide at the 20th week of pregnancy and dichorial diamniotic placenta were studied. In connection with the expressive autolytic changes in the internal organs of the fetus, which do not allow to confirm the diagnosis of left ventricular hypoplasia at autopsy and establish its type of structure, additional measurements of the heart structures of the fetus with HLHS on archived video materials of ultrasound diagnostics were performed. After calculating the diagnostic indices: the index of myocardial layer thickness (ratio of the thicknesses of the trabecular and compact myocardium), the index of cavity shape of the heart in frontal axis (ratio of width to cavity length), cavity-myocardial index (ratio of wall thickness to cavity width), the cylindrical LV structure was retrospectively determined, which is prognostically unfavorable any kind of surgical correction, which justified selective feticide. The article presents the values of diagnostic indices for identifying the types of structure of hypoplastic LV. Prenatal determination of LV type determines treatment tactics: terminate pregnancy in case of adverse LV types, recommend Norwood procedure in the neonatal period with type I or perform fetal aortic valvuloplasty with type II of LV. The maturation disorders (distal villous hypoplasia) that we found in the placenta of a living fetus confirms that, despite the relatively satisfactory condition of the newborn, pregnancies that occur with the use of IVF are high risk group of developmental disability both the fetus and placenta.

[The concept of chronic obstructive pulmonary disease clinical control as a decision - making tool in real clinical practice for optimizing of basic pharmacotherapy].

The main goals of COPD therapy are to achieve clinical stability with minimal clinical manifestations and low risk of relapse. The proposed COPD control concept by analogy with asthma has not been quite well characterized yet. COPD control is defined as "the long - term maintenance of a clinical situation with a low impact of symptoms on the patient's life and absence of exacerbations." The situation of clinical control in COPD is considered desirable and potentially achievable for most patients with COPD. Pharmacotherapeutic options for COPD are constantly expanding. The control concept may be useful when the decision on treatment of COPD is made for dynamic adjustment of the therapy volume.

[Severe bronchial asthma patient care organization in various regions of the Russian Federation. From endotypes and phenotypes of bronchial asthma to personalized choice of therapy].

The meeting of the Expert board was held in Moscow on June 24, 2019, at which the following issues were considered: the applicability of a new terminology characterizing asthma endotypes and phenotypes in real clinical practice, the effect of phenotypes and biomarkers in patients with bronchial asthma on the choice of biological drug, as well as the optimal clinical profiles of patients for whom dupilumab is most effective, taking into account the data of the III phase clinical trials, regional features of medical care and changes in updated international clinical guidelines for the diagnosis and treatment of asthma. The Expert board included members of leading Russian scientific and educational medical institutions: S.N. Avdeev, corresponding member of the Russian Academy of Sciences, prof., MD; O.A. Volkova, Ph.D.; I.V. Demko, prof., MD; G.L. Ignatova, prof., MD; I.V. Leshchenko, prof., MD; Kanukova N.A.; Kudelya L.M., prof., MD; V.A. Nevzorova, prof., MD; N.G. Nedashkovskaya; O.P. Ukhanova, prof., MD; L.V. Shulzhenko, prof., MD; R.S. Fassakhov, prof., MD.

[Systematic approach in performing isolated and simultaneous operations in elderly patients with prostate adenoma].

AIM: To develop a scientifically based system for treating elderly patient with prostate adenoma (AP), aimed at reducing the incidence and severity of complications and mortality after isolated and simultaneous operations. MATERIALS AND METHODS: Between 1995 and 2015, 1170 elderly and older patients with prostate adenoma (PA) underwent isolated adenomectomy (AE) or transurethral resection of the prostate (TURP) or simultaneous operations (SO). Simultaneous interventions were performed in 335 (28.6%) patients. RESULTS: Immediate treatment results were significantly better in patients who underwent isolated TURP or TURP as a part of SO than that of those who had isolated AE or AE as a part of SO. SO was not associated with greater incidence of local or general postoperative complications and mortality compared with isolated AE or TURP. CONCLUSION: Continuous advancements in diagnostic and treatment methods contributed to a significant reduction in the incidence of postoperative complications and deaths in geriatric patients with PA. The study findings confirm the superiority of TURP over AE, as previously reported by other authors.

[Choice of basic therapy for asthma in real clinical practice].

According to the Global Initiative for Asthma, the treatment of asthma should be mainly based on its control that encompasses symptom control and exacerbation risk reduction. Control-based treatment contributes to decreases in the frequency of exacerbations, the incidence of drug side effects, the needs of asthmatic patients for emergency care, and the number of their visits to a doctor and hospitalizations, resulting in a reduction of direct health care costs of asthma. Drugs for the basic therapy of asthma are chosen on the basis of evidence for their efficacy and safety and the view of availability and cost of treatment. In case of poor asthma control it is important to reveal its causes and to change basic therapy according to the individual needs of the patient. A major role in the achievement of asthma control is assigned to a combination of inhaled glucocorticosteroids (ICS) and long-acting ß2-agonists. Combined medications are prescribed to asthma patients in accordance with the daily ICS dose required to achieve asthma control.

[Exocrine function of the pancreas in rats with experimental obesity].

The influence of neonatal administration of hyperosmolar sodium chloride and sodium glutamate on the exocrine function of the pancreas in rats has been investigated. It was observed the development of acute pancreatitis under experimental obesity. The cross-section area of acini reduced by 12%, the cross-section area of acinocytes nuclei increased by 10%, the length between the lobes of the gland has grown by 48%. The level of amylase was increased by 43%, the levels of pancreatic amylase and lipase were increased by 68% and 24%, respectively.

[Community-acquired pneumonia: from national recommendations to regional standards].

UNLABELLED: Community-acquired pneumonia (CAP) is a major challenge facing health service. The aim of this work was to estimate the effectiveness of introduction of Sverdlovsk region territorial CAP standards into clinical practice in 2002-2011. MATERIALS AND METHODS: Retrospective analysis included 523 case histories of the patients who diedfrom CAP and 127 one who recovered after treatment (groups 1 and 2 respectively). The primary end-point was general and intrahospital mortality rate, secondary end-points the day of admission to the intensive therapy unit (ITI) and the onset of starting antibiotic therapy (ABT), conformity of ABT to the regional standard. Independent and patient/hospital-dependent risk factors of unfavourable outcome of CAP were subjected to statistical analysis. RESULTS: In 2002-2011 mortality rate among the able-bodied population and hospitalized patients with CAP decreased by 46 and 15.4% respectively (overall 30.7%). Chronic alcoholism, poor social status (to 53.9 +/- 2.4%), late application for medical aid (77% of the patients applied later than 3 days after the onset of CAP) were risk factors of unfavourable outcome. The time of CAP onset in groups 1 an d 2 was 5.7 +/- 10.3 and 2.2 +/- 4.5 hr respectively (OR: 5.31 [95% CI 2.32 = 12.16] p < 0.01). ABT conformed with the regional standards in 7.4 and 92.1% of the cases in groups I and 2. CONCLUSION: Strict compliance with national guidelines and regional programs ensures success of diagnostics and treatment of CAR

[Impact of the method choice and the extent of correction on the development of visual evoked potentials in children and adolescents with refractive anomalies].

The article discusses a possible impact of different refraction correction methods, providing full or partial correction, on visual acuity and the development of visual evoked potentials in children and adolescents with myopia and myopic astigmatism. The accuracy of identification of visual evoked potentials depends, as shown in the article, on the extent of the correction chosen and the method used. In childhood the visual system is very susceptible to visual afferent deficit. The permanent deficit of visual information impedes further maturation of the visual analyzer, i.e. the development of central vision, binocular vision, and stereopsis. In high myopia it is important to decide not only on the extent of the correction but also on the method to use. In patients wearing soft contact lenses the visual evoked potentials have more regular shape, amplitude, and latency. The introduction of silicone hydrogel and daily disposal contact lenses, spherical and toric (for astigmatism correction), provided an opportunity to solve hygienic problems associated with contact lens use in children and adolescents and to decrease the risk of hypoxia complications.

[Effect of basic therapy on clinical symptoms, quality of life and systemic inflammation in patients with chronic obstructive pulmonary disease].

The study included 38 men with moderately severe chronic obstructive pulmonary disease (COPD) (mean age 60.6 ± 10.2 yr) and 42 ones with severe COPD (mean age 61.2 ± 7.2 yr). They were treated with tiotropium bromide, formoterol and beclomethasone dipropionate for 24 weeks (stage 1), TB alone for 12 weeks (stage 2) and TB+formoterol (long-acting bronchodilators, LABD) for another 12 weeks. Each stage was followed by evaluation of COPD symptoms using the St-George's Hospital questionnaire, daily requirements for short-acting beta-2 agonists (SABA), heart rate (HR), forced expiratory volume in the 1st second (FEV-1) before and after SABA test, hemoglobin saturation with oxygen in arterial blood during pulse oxymetry before and after 6 min walking test, blood surfactant protein D level (SP-D). The control group was comprised of 34 healthy men (mean age 62.3 ± 5.8 yr). Patients with moderately severe COPD experienced worsening of clinical symptoms (p < 0.001), required more SABA (p < 0.001), had increased HR (p = 0.01) and SP-D levels (p = 0.01) whereas FEV-1 (p = 0.05) decreased during stage 2 as compared with stage 1. Positive dynamics of all these variables except COPD symptoms and HR was observed at stage 3. Alteration in the extent of basal therapy in patients with stage III COPD did not result in dynamics of clinical and laboratory characteristics. The data obtained suggest the necessity of combined therapy with LABD or triple basal therapy of moderately severe COPD and the possibility of therapy with one or two LABD having different sites of action in the patients with clinically stable stage II COPD.

[Chronic obstructive pulmonary disease exacerbation. Do we use all possibilities of outpatient therapy?].

Chronic obstructive pulmonary disease (COPD) exacerbations are evaluated from a history of the disease, its clinical symptoms, and laboratory tests. The most common causes of a COPD exacerbation are upper respiratory tract and tracheobronchial infections. The exacerbation severity usually corresponds to the magnitude of clinical manifestations of COPD during its stable course. Successful treatment in patients with a COPD exacerbation is determined by its timely diagnosis. When treating patients with a mild or moderate exacerbation of Stages I-II COPD in an outpatient setting, it is advisable to use ascoril having broncholytic, mucolytic, and mucokinetic properties along with antibiotics and glucocorticosteroids, if clinically indicated.

[Estimation of the risk and prevention of postoperative esophagogastroduodenal hemorrhage in elderly urological patients].

Open transvesical adenomectomy was made in 853 old males with prostatic adenoma in Samara Hospital for Veterans from 1995 to 2010. The age of the patients ranged from 60 to 89 years, of them 389 (45.6%) were from 60 to 75 years of age, 464 (54.4%) - 75 to 89 years. Elective simultaneous operations were conducted in 104 (12.2%) of the above patients. It is shown that early postoperative esophagogastroduodenal hemorrhage after adenomectomy occurs in 7% old patients. Endoscopic parietal pH-metry is "a gold standard" in selective sensitive diagnosis of acid-dependent conditions in presenile and senile patients with prostatic adenoma. The proposed method of prediction of the risk of early postoperative esophagogastroduodenal hemorrhage provides realization of the principle of a differential approach to effective prevention of the hemorrhage in old patients with prostatic adenoma. Complex preoperative preparation using adequate antisecretory therapy in old patients with prostatic adenoma with the risk of early postoperative esophagogastroduodenal hemorrhage decreases hemorrhage rate from 7 to 0.4%. Prevention of early postoperative esophagogastroduodenal hemorrhage in old patients with prostatic adenoma should become as obligatory as prevention of cardiovascular, thromboembolic, pulmonary and pyoseptic complications.

[The influence of long-term monosodium glutamate feeding on the structure of rats pancreas].

The influence of prolonged administration of monosodium glutamate (MSG) on pancreas in rats was studied. It was established that 30-days feeding by MSG in the doses 15 to 30 mg/kg (equivalent to 1 and 2 g/person) leads to necrotic, necrobiotic and degenerative changes in exocrine and endocrine cells, leukocytic and lymphoid infiltration, perivascular and interstitial fibrosis, edema and discirculatory disorders. Introduction of sodium glutamate increases the cross-sectional area of nuclei ofexocrine and endocrine cells, indicating intensification of synthetic processes in the cells of the pancreas and reduces the cross-sectional area of exocrine pancreatic cells, which is a sign of stimulation of secretory processes in exocrine cells. The changes described are characteristic of the acute pancreatitis. It is concluded that the maximum daily dose of food supplements containing glutamic acid and its salts should be reviewed because of their adverse effects on the pancreas. It is concluded that the maximum dose of MSG should be reconsidered taking into account its influence on the pancreas.

[Elective simultaneous operations in elderly and senile urological patients].

Surgeons of Samara Regional Veterans' Hospital made elective-simultaneous operations in 229 presenile and senile patients. Surgery was performed in the urological department in 1995-2010. It is shown that over 12% patients of urological geriatric departments need elective situltaneous operations, of them 8.7% are mild, 78.6%--moderate and 12.7%--severe. The results of simultaneous operations in 133 patients and staged operations in 60 control patients (adenomectomy and Vinkelman) differed insignificantly (p > 0.05). Such achievement was realized due to advanced prophessional education of all medical personnel of the department, introduction of new techniques in examination and treatment: accurate definition of absolute and relative contraindications for simultaneous surgery, effective preoperative preparation, low-invasive operations, different variants of non-endotracheal anesthesia. In addition to a positive clinical effect, new technology of simultaneous operations reduces 2.3-fold economic costs vs staged surgery, improves significantly quality of life of the above patients.

[Clinical features and delayed aftereffects of Legionellosis pneumonia during an epidemic outbreak].

The aim of this work was to study specific clinical features of legionellosis pneumonia during an epidemic outbreak of the disease in Sverdlovsk region and to assess its delayed effects. 202 patients applied for the treatment to the central hospital of the town of Verkhnyaya Pyshma in July-August 2007 Legionella pneumophila was identified in 61 adults aged 51.3-59.3 (mean 55.3) years. The following analyses were performed at admittance and discharge as well as 1 year after treatment: complete blood count, urinalysis, AST, ALT and sugar levels, breast X-ray and ECG. Patients with mild disease were given azithromycin per os (500 mg for 7days, n = 10) or levofloxacin (500 mg for 10 days, n = 5). Those with the severe form of the disease were treated with azithromycin (500 mg for 3 days, v/v, n = 17) or levofloxacin (750 mg for 2-3 days v/v and for 12 days per os, n = 29). The results were analysed using the STATA 5.0 software package (Stata Corporation, College Station, Texas, USA). Difference were considered significant at p < 0.05. It was shown that the outbreak resulted from the use of hot water from the public water supply system contaminated with L. pneumophila. The incubation period of infection was 4.48-6.01 (mean 5.3) days. Duration of hospitalization varied from 9.6-12.9 (mean 11.3) days. Most common clinical symptoms: general uneasiness, headache, non-productive cough, and fever lasting 3.8-6.6 (mean 5.2 days). Intrahospital lethality 6.6%. It is concluded that therapy with azithromycin and levofloxacin give good clinical effect leaving no systemic lesions in patients with legionellosis pneumonia.

[Organization of medical care of patients with pneumonia caused by Legionella during outbreak in Sverdlovsk region].

Data on organization of medical care during outbreak of Legionnaires' disease in July-August, 2007 in town Verkhnyaya Pyshma in Sverdlovsk region are presented. Special feature of this outbreak was spreading of infection in boundaries of the town with total population of 70,600 people. Results of organizational work of health authorities in order to provide timely and adequate medical care for patients with Legionnaires' disease on both outpatient and inpatient levels of care, conduction of preventive measures in foci of infection, coordination of interaction between different medical organizations and services are summarized in the article.