['Stroke chameleons']. / 'Insul'ty-khameleony'.

The diagnosis of acute stroke should be correct and early that allows physician planning the most effective treatment strategies (reperfusion therapy, undifferentiated (basic) treatment, early secondary prevention). However, stroke symptoms can be atypical and similar to some other (non-vascular) event. It can significantly complicate the clinical diagnosis of stroke and decrease the patient's chances for effective treatment. A stroke should be suspected in every patient with acute onset of neurological symptoms, especially when the patient has the 'vascular' risk factors. Furthermore it is important to remember that negative CT-scan data and/or MRI data do not exclude the presence of not only ischemic stroke but also hemorrhagic stroke. The article describes the main variants of strokes with atypical symptoms (strokes-chameleons), emphasizes the importance of careful clinical examination, provides supportive differential diagnostic criteria and discusses limitations of neuroimaging methods.

[Limb-shaking transitory ischaemic attack in a patient with subocclusion of the internal carotid artery]. / Tranzitornaia ishemicheskaia ataka «limb shaking¼ u bol'nogo s subokkliuziei vnutrennei sonnoi arterii.

Described in the article is a clinical case report concerning symptomatic subocclusion of the internal carotid artery in a male patient with a rare variant of recurrent limb-shaking transitory ischaemic attacks (LS-TIA). The patient presented with a three-month history of episodes of involuntary jerky movements in his left hand. These episodes occurred invariably on assuming a vertical position. The findings of duplex scanning revealed subocclusion of the right internal carotid artery. The patient was subjected to stenting with the use of the system of proximal cerebral protection. The postoperative period was complicated by the development of cerebral hyperperfusion syndrome the risk of which in patients with LS-TIA is known to be elevated. Via telephone interviewing carried out at 1, 6 and 12 months after the intervention, the patient confirmed that the episodes of hand shaking did not recur. This case report highlights the importance of accurately assessing the clinical findings while selecting patients for carotid revascularization, since such ischaemic episodes are strongly suggestive of a severe lesion of the contralateral carotid artery. Once subocclusion is revealed, it is optimal to perform stenting with the use of a system of proximal protection, as a safer and more effective method of surgical revascularization in such conditions.

[Hemodynamic Predictors of Clinical Deterioration in Patients With Pulmonary Arterial Hypertension Associated With Systemic Scleroderma].

OBJECTIVE: to elucidate hemodynamic predictors of clinical deterioration (CD) in patients with pulmonary arterial hypertension (PAH) associated with systemic scleroderma (SSD). MATERIAL AND METHODS: We included into this study 48 patients with PAH-SSD consecutively admitted in 2004-2014. At inclusion all patients underwent right heart catheterization (RHC) and thereafter were under dynamic observation. CD deterioration was diagnosed in the presence of the following: >15% decline in 6-minute walk test distance; worsening of PAH functional class; intensification of symptoms of right ventricular failure; necessity in administration of parenteral diuretics. RHC was used for confirmation of CD. Relative risk (RR) of events was calculated for identification of significant predictors of CD. Cut points were determined with the help of construction of characteristic curves, statistical significance was estimated in Kaplan-Meier analysis. RESULTS: During follow-up (duration 46 [23;91] months) 21 patients had 24 CDs confirmed by RHC. Calculation of RR identified a number of hemodynamic parameters related to CD development. ROC analysis confirmed significance of initial right atrial pressure (RAP) 6.5 mm Hg (95% confidence interval [CI] 0.59-0.89, sensitivity 71%, specificity 63%, p<0.004) and dynamics of pulmonary vascular resistance (PVR) -1.06 Wood units (95%CI 0.790.99; sensitivity 76%, specificity 80%, <0.0001). Kaplan-Meier analysis revealed significant differences in times to CD (median 31.5 and 10 months in patients with RAP <6.5 and more or equal 6.5 mm Hg, respectively, p=0.01; 37 and 17months in patients with PVR lowering >1.06 Wood units and no PVR lowering, respectively, p=0.009. CONCLUSION: We identified prognostic levels of key hemodynamic predictors of CD in patients with SSD and PAH (RAP 6.5 mm Hg, PVR - 1. 06 Wood units) which can be used for individualization and optimization of therapy.

[Clinical and hemodynamic characteristics and possibilities for therapy in patients with severe (functional class IV) pulmonary arterial hypertension associated with diffuse connective tissue diseases].

AIM: To study the clinical and hemodynamic characteristics of a group of patients with Functional Class (FC) IV pulmonary arterial hypertension (PAH) developing in the presence of diffuse connective tissue diseases (DCTD) and to evaluate the efficacy of intravenous iloprost. SUBJECTS AND METHODS: The study enrolled 59 patients with PAN-DCTD, including 7 who had FC IV and 8 who developed this condition during a follow-up. The diagnosis of PAH was based on pulmonary artery catheterization findings. FC IV was diagnosed using the conventional New York Heart Association classification. All the patients received PAH-specific therapy (bosentan, sildenafil); the patients with FC IV had combined therapy; 4 patients were treated with intravenous iloprost calculated with reference to 0.5-2.5 ng/kg/min for 15 days. In addition to the patients with FC IV, 3 patients with unstable FC Ill were given iloprost. Besides targeted therapy, all the patients received standard treatment, including diuretics, and ionotropic therapy. RESULTS: Evaluation of hemodynamics in patients with different FCs revealed the most important differences in right atrial pressure, cardiac output, cardiac index, and pulmonary vascular resistance. A linear relationship was seen between the level of this indicator and FC, the closest correlation being for hemodynamic parameters characterizing right ventricular systolic function. There were no changes in mean pulmonary artery pressure; only the patients with FC IV were found to have its slight elevation (from 52 ± 15 to 55 ± 11 mm Hg). Pulmonary artery wedge pressure remained unchanged regardless of FC. Intravenous iloprost was noted to have an obvious positive effect on both clinical and hemodynamic parameters. Catheterization verified improvement in 6 out of the 7 patients; no hemodynamic changes were found in 1 patient during 15-day therapy. CONCLUSION: The patients with FC IV PAH-DCTD have clinical and hemodynamic features responsible for a fatal prognosis. The results of using intravenous iloprost in patients with decompensated PAH associated with scleroderma systematica convince to use its PAH-specific tablets in cases of verified clinical deterioration when taking its dosage form.

[Impact of bosentan therapy on stress-induced pulmonary hypertension in patients with systemic sclerosis].

AIM: To describe hemodynamic and clinical changes in patients with elevated mean pulmonary artery pressure (MPAP) > 30 mm Hg during exercise and the impact of bosentan therapy on stress-induced pulmonary hypertension (SIPH). SUBJECTS AND METHODS: The study included 19 patients with systemic sclerosis (SDS) in whom possible causes of pulmonary hypertension (PH) (lung and left heart injuries and thromboembolism) were excluded. All the patients underwent pulmonary artery catheterization at rest and during exercise. The hemodynamic (right atrial pressure (RAP), systolic and diastolic pressure, MPAP, pulmonary artery wedge pressure (PAWP), cardiac output (CO) by a thermodilution technique), clinical (demographic, immunological, and instrumental) parameters were analyzed and the risk of pulmonary arterial hypertension (PAH) was also calculated; 5 patients with SIPH received 16-week bosentan therapy according to the conventional regimen. RESULTS: Ten of the 19 patients were at increased risk for PAH in accordance with the DETECT scale, but no signs of PH at resting catheterization were found in anybody. In 5 patients, MPAP, was in the range from 21 to 24 mm Hg; in 9 (47%) patients were found to have SIPH, a median MPAP of 35 (32; 41) mm Hg. Seven patients had no diagnostic changes during exercise; 3 patients could not perform an exercise test. There were correlations between MPAP and DETECT risk scores (p < 0.05). The patients with SIPH had significantly higher levels of resting MPAP and exercise pulmonary vascular resistance (PVR) and PAWP. The calculated DETECT risk was significantly higher in the SIPH group. The level of uric acid was also higher in the SIPH group (p < 0.05). There were no changes in NT-proBNP levels, telangiectasias and anti-centromere antibodies, and EchoCG and lung test results. During 16-week bosentan therapy, there was a significant decrease in MPAP and transpulmonary gradient during exercise, but PVR, MPAP/CO ratio and NT-proBNP levels tended to decrease. CONCLUSION: In the patients with SDS, SIPH may be a stage of pulmonary vasculopathy that precedes the development of clinical PAH. The use of current PAH-specific drugs used at the preclinical stage of the disease may substantially improve lifetime prognosis in patients with SDS-associated PAH.

[Survival in pulmonary arterial hypertension, associated with connective tissue diseases, treated by sildenafil: results of the prospective study].

AIM: To investigate the effect of sildenafil on the survival of patients with pulmonary arterial hypertension (PAH) associated with connective tissue diseases (CTD), who have been followed up at the Rheumatology Expert Center. SUBJECTS AND METHODS: A total of 16 patients (all women) with PAH associated with CTD, who had been admitted to the V. A. Nasonova Research Institute of Rheumatology in 2013-2015, were examined. PAH corresponded to Functional Class II in the majority of the patients. After the diagnosis was verified by catheterization of the right heart and pulmonary artery, all the patients received original sildenafil (a phosphodiesterase type 5 inhibitor, a potent vasodilator, the efficiency of which was proven in patients with PAH) at a dose of 20 mg thrice daily. Survival rates and time to clinical deterioration were estimated during a prospective follow-up). RESULTS: Three-year survival rates were 94% in the study group and 25% in the group of historical control (p < 0.05). The time to clinical deterioration was associated with the duration of the follow-up and hemodynamic parameters (right atrial pressure and changes in vascular resistance within 4 months after therapy initiation). CONCLUSION: The administration of sildenafil substantially improves survival in patients with PAH associated with CTD as compared with the historical control. The identification of poor prognostic factors in this cohort of patients and early diagnosis will favor the personification of therapy for the fatal manifestation of CTD.

[Bosentan: a considerable increase in the survival of patients with pulmonary hypertension associated with systemic rheumatic diseases].

AIM: To evaluate the short-term efficacy of the nonselective endothelin receptor antagonist bosentan in the treatment of pulmonary hypertension (PH) associated with diffuse connective tissue diseases (CTD), as well as its effect on survival in both monotherapy and in combination with other PH-specific agents. SUBJECTS AND METHODS: The study included 20 CDT-associated PH patients who had been hospitalized in 2009-2013. All the patients had valid diagnoses of scleroderma systematica (SDS) (n = 18) or systemic lupus erythematosus (SLE) (n = 2). Bosentan was given in an initial dose of 62.5 mg/day twice for 4 weeks, then 125 mg/day twice. RESULTS: Eighteen patents completed therapy at 16 weeks. One patient with Functional Class (FC) IV PH associated with SDS died after 10 weeks of treatment because of PH progression; bosentan was discontinued in another patient following 4 weeks because of the enhanced activity of transaminases. The patients who had completed the investigation showed a significant FC decrease (from 2.9 +/- 1.0 to 2.4 +/- 1.0 following 16 weeks; p = 0.03), an increase in 6-minute walking distance (from 298 +/- 140 to 375 +/- 94 m; p < 0.002), a significant reduction in mean pulmonary artery pressure (from 48.2 +/- 15.0 to 42.8 +/- 12.0 mm Hg; p = 0.002), and pulmonary vascular resistance (PVR) (from 819 +/- 539 to 529 +/- 220 din/sec/cm(-5); p = 0.003). Right atrial pressure fell from 9.8 +/- 7.0 to 8.8 +/- 7.0 mm Hg; however, the changes were insignificant. There was a significant rise in cardiac index from 2.64 +/- 0.95 to 3.26 +/- 0.75 l/min/m2 (p = 0.005) and a significant decrease in uric acid levels from 562 +/- 254 to 469 +/- 194 micromol/l (p = 0.006). Overall 1-, 3-, and 5-year survival rates in patients with PH in the presence of CTD from PH onset were 100, 93, and 72%, respectively, in their treatment with endothelin receptor antagonists and differed significantly from the historical control group (87, 30, and 4%, respectively) when PH-specific therapy was unavailable. CONCLUSION: The survival of the bosentan-treated patients with SDS and PH becomes similar to that in the patients with classical SDS. Analysis of the findings revealed the association of survival with lower PVR at 16 weeks of bosentan therapy, which is indicative of the need for hemodynamic monitoring of therapeutic effectiveness.

[Long-term follow-up of patients with refractory systemic lupus erythematosus during rituximab treatment].

AIM: To evaluate the impact of anti-B-cell therapy on the clinical and immunological parameters of systemic lupus erythematosus (SLE) activity, on the time course of changes in these parameters during long-term follow-up, and on the tolerability of repeated rituximab (RTM) therapy cycles. SUBJECTS AND METHODS: RTM was given to 97 patients with high activity of SLE refractory to treatment with glucocorticosteroids (GCS) and cytostatics. The follow-up lasted 18 (12-36) months. The most common clinical manifestations of SLE were lupus nephritis (LN) (62%) and skin (33%) and nervous system (22.7%) involvements. Clinical SLE activity was assessed applying the SLE disease activity index 2000 (SLEDAI2K); therapeutic effectiveness was evaluated using indicators, such as partial response (PR), complete response (CR) and exacerbation. The exacerbation was classified as moderate and severe using the Selena-Sledai Flare index (SFI). RESULTS: Depletion was identified in 78% of the patients with SLE immediately after RTM therapy. During 3.5 years of follow-up, the effect of RTM was seen in 82% of the patients after repeated RMT therapy cycles (CR 56% and PR 28%). Exacerbations were observed in a total of 24 (24.7%) patients; the exacerbation lasted 12 (12-24) months after RTM therapy: of them 17.5% with LN and 7.2% with extrahepatic manifestations of SLE (exacerbations occurred 12 (12-24) and 18 (6-48) months after RMT therapy). In 24 exacerbated patients, B cells recovered at 6 (3-12) months. A year after RMT therapy, a group of 35 patients who were observed to have complete B cell depletion achieved CR statistically significantly more frequently than a group of 20 patients who had B-cell recovery (65.7 and 30% respectively, p = 0.03). CR was observed significantly more often in patients after repeated RTM therapy cycles than those who had received only one RTM therapy cycle (p = 0.02). The long-term follow-up showed a reduction in SLEDAI2K, normalization of laboratory values, and a decrease in the daily dose of GCS. Most patients tolerated well both the first and repeated RTM therapy cycles. CONCLUSION: According to the results of the long-term follow-up, RTM therapy is a highly effective treatment option for SLE patients in whom the previous standard therapy with GCS and cytostatics was previously ineffective. The 3.5-year follow-up showed a good tolerability of RTM and revealed no increase in the risk of infectious complications or adverse reactions.

[Biological activity of fungi from the phyllosphere of weeds and wild herbaceous plants].

Antimicrobial, phytotoxic, and insecticidal activity of 30 fungal isolates obtained from leaves of weeds and wild herbaceous plants was assessed. Antibacterial, antifungal, phytotoxic, and insecticidal activity was found in over 50, 40, 47, and 40% of the isolates, respectively. These findings may be important for toxicological assessment of potential mycoherbicides, as well as provide a basis for investigation of the patterns of development of phyllosphere communities affected by fungal metabolites.

First Report of Bacterial Spot of Tomato Caused by Xanthomonas gardneri in Pennsylvania.

Recent investigation of bacteria isolated from samples submitted to the Plant Disease Diagnostic Laboratory, Pennsylvania Department of Agriculture indicated that in 1995, Xanthomonas gardneri (ex Sutic 1957) (2) caused a leaf spot on tomato plants (Lycopersicon esculentum Mill.). In 1995, we examined 185 tomato and 36 pepper samples (13 field, 2 garden center, 38 greenhouse, 4 residence, 16 field-grown transplant, and 148 greenhouse-grown transplant samples). A processing company representative collected samples showing symptoms of bacterial spot of tomato on a hybrid, whole pack processing tomato, from a 16-ha field in Northumberland County, PA exhibiting almost 50% crop infection. Symptoms consisted of circular- to irregularly shaped, dark brown spots, <5 mm in diameter, and frequently with chlorotic haloes on leaves and stems. The center of a spot may be raised and scabby. Several spots on a single leaflet may coalesce and a portion or the entire leaflet may turn yellow or die. These symptoms were indistinguishable from those of bacterial spot caused by X. euvesicatoria, X. vesicatoria, and X. perforans. Bacterial streaming from lesions was evident under dark-field microscopy. Aerobic, gram-negative, yellow-pigmented, mucoid bacteria were isolated from the leaf spots and purified and stored in nutrient broth with 10% glycerol at -80°C. The 16S rRNA gene from a strain (PDA80951-95) typical of the cultures from these samples was sequenced (GenBank Accession No. GU573763). A BlastN search of GenBank revealed 100% nucleotide identity with the type strain of X. gardneri (XCGA2; No. AF123093). This strain also exhibited repetitive sequence-based (rep)-PCR profiles (4) identical to profiles of X. gardneri type strain XCGA2 DNA and produced a ~425-bp PCR product with BSX primers, a genetic marker indicative of X. gardneri (1). The strain was not amylolytic or pectolytic (2) and failed to utilize maltose, gentiobiose, and melezitose (3). For pathogenicity tests, inoculum was grown in nutrient broth with shaking for 24 h at 28°C. Inoculum was centrifuged, resuspended in sterile tap water, and adjusted to 2.5 × 108 CFU/ml. Lower leaf surfaces of tomato (cvs. Bonnie Best and Walter) and pepper (cvs. California Wonder and Early Niagara) plants were gently rubbed with sterile cheesecloth that was moistened with the inoculum. Strain PDA80951-95 caused leaf spots, with chlorotic haloes and occasional coalescence on both tomato and pepper, within 2 weeks at 15 s of mist per 20 min at 20 to 35°C in a secured greenhouse chamber. X. gardneri was only reisolated from symptomatic plants and its identity was confirmed by rep-PCR and absence of amylolytic and pectolytic activities. Negative controls consisting of X. campestris pv. campestris and sterile tap water did not show symptoms. A known type strain of X. gardneri was not included as a positive control for pathogenicity studies because this species is not known to occur in the United States (2). To our knowledge, this is the first report of bacterial spot on tomato plants caused by X. gardneri in Pennsylvania and the United States. Since the first occurrence in 1995, bacterial spot caused by X. gardneri reoccurred in Pennsylvania tomato fields in 2001 and consecutively from 2003 to 2009. Reference: (1) D. A. Cuppels et al. Plant Dis. 90:451, 2006. (2) J. B. Jones et al. Syst. Appl. Microbiol. 27:755, 2004. (3) A. M. Quezado-Duval et al. Plant Dis. 88:15, 2004. (4) D. J. Versalovic et al. Methods Mol. Cell Biol. 5:25, 1994.

[Advantages of the use of Andro-Gin device for treatment of secretory infertility].

The trial included 144 patients aged from 24 to 46 years with secretory infertility in the presence of chronic prostatitis of 2 to 13 year duration. The study group consisted of 96 patients who received conventional treatment in combination with physical factors provided by the unit APK-ELM-01 Andro-Gin. The control group consisted of 48 patients on conventional treatment alone. The results were processed mathematically and statistically. The patients were examined before, 2 weeks, 1 and 6 months after the treatment. Positive response was greater in the study group: better parameters of prostatic secretion, spermogram. Normalization of all the parameters occurred in 95 and 80% patients of the study and control groups, respectively. Thus, Andro-Gin is effective for treatment of chronic prostatitis with secretory infertility.

[Vaccine prophylaxis in elderly patients]. / O taktike vaktsinoprofilaktiki u pozhilykh liudei.

In 1997-1999 observation was made on elderly people living in old people's homes and in families, as well as groups of young males living in hostel-type homes, altogether 4,518 subjects. Standard inactivated whole-virion influenza vaccine was introduced in a dose of 0.5 ml subcutaneously in a single injection or intranasally in two administrations. In control groups placebo was used. The frequency of seroconversions to vaccine strains of influenza viruses was significantly less in elderly people than in young people following both subcutaneous and intranasal immunization (on the average, by 15-20%). In young people the prophylactic effectiveness of the vaccine introduced intranasally was the same as after subcutaneous immunization with the effectiveness index (EI) being equal to 2.1-2.8. In elderly people the effectiveness of the vaccine after subcutaneous immunization was the same as in young people (EI = 1.7-2.7), but insufficient after intranasal immunization (EI < or = 1.6). The preparation "Amber elixir plus" enhanced the effectiveness of immunization against influenza in elderly people.

[Effect of draining the thoracic lymph duct on the protein level of blood and lymph in peritonitis]. / Vliianie drenirovaniia grudnogo limfaticheskogo protoka na uroven' belka v krovi i limfe pri peritonite.

Under study were specific features of protein metabolism in 52 patients with peritonitis treated by routine methods. In 26 of them the external lymph drainage was used with a compensation of lymph loss. Lymph drainage in peritonitis results in detoxication of organism and normal protein-synthesizing function of the liver.

[Alkaline phosphatase in the blood and lymph in diffuse peritonitis]. / Shchelochnaia fosfataza krovi i limfy pri razlitom peritonite.

Activity of alkaline phosphatase was studied in blood and lymph of 52 dogs with experimental peritonitis and in 26 patients with the drained thoracic duct and in 26 patients without lymphodrainage. Pronounced enzyme intoxication was revealed. Under physiological conditions alkaline phosphatase is transported by both blood and lymphatic bed. In peritonitis the lymphatic route of the enzyme transport gets considerably greater. Drainage of the thoracic duct gives good detoxicating effect (decreased alkaline phosphatase activity).