О Б Щ А Я Р Е А Н И М А Т О Л О Г И Я , 2 0 1 3 , I X ; 5 45 В п о м о щ ь п р а к т и к у ю щ е м у в р а ч у Цель исследования-анализ изменений электрической активности (ЭА) желудочноокишечного тракта (ЖКТ) у больных в критических состояниях (КС), оценка эффективности их учета в клинической практике на примее ре прогнозирования действия глутамина. Материалы и методы. Обследовано 249 пациентов в КС (131 мужж чина, 118 женщин, 68±17 лет, больных «терапевтического профиля»-97, «хирургического»-152). Выделее но 2 группы больных: контрольная (n=186)-без дополнительного применения к терапии глутамина и основная (n=63)-с добавлением глутамина 0,5 г/кг/сутки, в течение 5-10 дней (энтерально или внутривенно в зависии мости от выраженности синдрома кишечной недостаточности (СКН)). Выполнена автоматическая классифии кация больных по показателям ЭА ЖКТ. Исследована взаимосвязь изменений ЭА ЖКТ с АРАСНЕ II, SAPS II, SOFA, LOD, СКН, 288дневной выживаемостью в отделении реаниматологии (ОР). Оценены точность вероятт ностного прогноза при одновременном учете состояния 7 органных систем и 288дневная выживаемость при применении глутамина в зависимости от показателей АРАСНЕ II и типа ЭА ЖКТ. Результаты. Установлено 2 типа ЭА ЖКТ при КС-умеренных (I тип) и значительных (II тип) изменений по сравнению с показателями нормы. При нарастании общей тяжести состояния и выраженности СКН вне зависимости от «профиля» забоо левания отмечали однонаправленные изменения ЭА ЖКТ, их умеренную взаимосвязь с показателями АРАСНЕ II, SAPS II, SOFA, LOD, стадией СКН-и достаточно высокую-с 288дневной выживаемостью. При применении глутамина получали увеличение 288дневной выживаемости у пациентов с АРАСНЕ II > 15 и II тии пом ЭА ЖКТ. Заключение. Нарушения гастроинтестинальной ЭА при КС носят характер типового патологичее ского процесса, их учет увеличивает точность вероятностного прогноза и эффективность применения глутамии на при КС. Ключевые слова: критические состояния, желудочноокишечный тракт, периферическая электрогастроэнтерография, глутамин. Objective: to analyze changes in the electrical activity (EA) of the gastrointestinal tract (GIT) in critically ill patients and to evaluate its impact in clinics by using the effect of glutamine as an example. Subjects and methods. Examinations were made in 249 critically ill patients (131 men and 118 women at the age of 68±17 years), including 97 and 152 therr apeutic and surgical patients, respectively. Two patient groups were identified: these included a control group (n=186) treated without glutamine therapy and a study group (n=63) additionally receiving glutamine 0.5 g/kg/day for 5 to 10 days (enterally or intravenously in relation to the magnitude of intestinal failure (IF)). The patients were automaticall ly classified according to the values of GIT EA. The authors studied a relationship of the changes in the latter to APACHE II, SAPS II, SOFA, LOD, IF, and 288day survival in the intensive care unit (ICU). The accuracy of probaa bilistic prediction was estimated, by simultaneously considering the sta...
Problema vozniknoveniya i vozmozhnyye prichiny trombogennosti u patsiyentov s ishemicheskim insul'tom (II) na fone istinnoy politsitemii (IP) ostayetsya aktual'noy. Tsel'yu issledovaniya bylo opredelit' kompleks faktorov, assotsiirovannykh s formirovaniyem vysokoy trombogennosti u patsiyentov s II na fone IP. Provedeno kompleksnoye kliniko-laboratornoye obsledovaniye 127 patsiyentov v ostreyshem periode II i spustya 16–18 mesyatsev: 68 patsiyentov s II na fone istinnoy politsitemii IP (osnovnaya gruppa) i 59 patsiyentov s II bez IP (gruppa sravneniya). Laboratornoye obsledovaniye vklyuchalo opredeleniye gemoreologicheskikh parametrov, pokazateley sistemy gemostaza, funktsii endoteliya, aktivnosti angiogeneza, tsitokinovogo i vospalitel'nogo ryada, molekulyarno-geneticheskoye issledovaniye mutatsii V617F v gene JAK2 i analiz vklada ikh izmeneniy v razvitiye trombogemorragicheskikh oslozhneniy. Obnaruzheno, chto nevrologicheskaya kartina v obeikh gruppakh byla bez znachimykh razlichiy so sredney otsenkoy po shkale NIHSS 12 i 13 ballov sootvetstvenno. Otmecheny osobennosti morfofunktsional'nykh kharakteristik eritrotsitov i trombotsitov, a takzhe gemostaziologicheskogo i tsitokinovogo profilya u patsiyentov s II na fone IP po sravneniyu s gruppoy sravneniya. Odnim iz klyuchevykh elementov v potentsiirovanii tromboticheskikh oslozhneniy u patsiyentov s II i IP stala velichina allel'noy nagruzki mutatsii V617F v gene JAK2. Poluchennyye dannyye svidetel'stvuyut o sovokupnom deystvii kompleksa faktorov, formiruyushchikh vysokuyu trombogennost' u perenesshikh II patsiyentov s IP i preodolevayushchikh summarnyy effekt antitromboticheskoy terapii.
The present article addresses the definition of cerebral amyloid angiopathy (CAA) and its symptoms based on the analysis of the medical case; the issues of diagnosis and treatment of this pathology are discussed. The Boston criteria, which became the basis for diagnosis, study of clinical manifestations and progression of CAA and approaches to its therapy, are presented. Methods and modes of neuroimaging, including magnetic resonance imaging (MRI), which verify micro cerebral haemorrhage, are described. At the same time, the role and significance of cardiac arrhythmias in the genesis of ischemic stroke are discussed, and scales for assessing the risk of its occurrence are presented. The observation of the neurological, somatic, neuroimaging, neuropsychological status of a 62-year-old patient confirms quite rare combination of probable CAA, paroxysmal atrial fibrillation and repeated hemorrhagic functional apoplexy (FA). The relevance of the case described, is a complex clinical dilemma based on mutually exclusive recommendations for the pharmacological correction of such conditions. It is emphasized that in many multicenter clinical studies on the effectiveness of antithrombotic medication (antiaggregants, anticoagulants) in the treatment and prevention of ischaemic functional apoplexy , an important exclusion criterion is a hemorrhagic stroke in past history (including the multiple changes in haemostasis indicators). Taking into account the obtained clinical and laboratory data in the dynamics, the tactics of treating the described patient were determined. The results of studies related to the treatment of comorbid pathology that should become the subject of the development of a personalized algorithm for managing patients in each specific case, are discussed.
Introduction. Thrombosis diagnosis and prevention in patients with Polycythemia vera (PV) suffered an ischemic stroke (IS) are still open. The aim was to find the reasons for systemic thrombogenicity and to compare the applicability of the main scales assessing thrombosis risk in patients with PV suffered IS.Materials and methods. We followed up 127 people (42-75 y.o.), of which 68 were patients with PV suffered IS (group I) and 59 non-PV-patients with ischemic stroke (group II). Clinical study included common blood analysis, rheological properties of erythrocytes, coagulation and endothelial parameters, cytokines, inflammation markers, angiogenesis markers, and testing for the V617F mutation in the JAK2 gene. The follow up included common and neurological examinations as well, and the assesment of thrombosis risk factors with both Caprini scale and CHA2DS2-VASc scale. All patients were examined twice as in the acute period of IS as well as in 16-18 months.Results. Between the groups no significant differences were found for the NIHSS average score and for Bartel index as well.The Caprini score belonged to the “very high risk” (score > 6) in both groups in the acute period of IS. At the same time, the score “8-10 points” prevailed in group II (68%) whereas the score “11-12 points” prevailed in group I.In the acute time of IS the CHA2DS2-VASc score revealed 12% of patients from both groups who had a score of “3-4 points” (moderate risk of thrombosis).In group I thrombotic complications rate correlated significantly with the JAK2V617F gene allelicloading (r = 0.236; p < 0.05), and the development of recurrence cerebrovascular disorders correlated significantly with Caprini score (r = 0.241; p < 0.05), but not with CHA2DS2-VASc score.Aiming to predict thrombotic complications in PV-patients the threshold (cut off) points were established for those markers as factor VIII, factor VII, red blood cell deformability, thrombin activated fibrinolysis inhibitor (TAFI), red blood cell count, white blood cell count, t-PA, VEGF-A, p-thrombomodulin, and ADAMTS-13.This pattern of parameters showed the odds ratio of thrombotic complications 10.3 (95% CI 7.6-13.8) in PV-patients in thelong-term period.At the end of the follow up the Caprini score showed a trend towards a decreasing in total while the CHA2DS2-VASc score remained virtually unchanged.Conclusion. We assume the accurate assessment of thrombotic risk in patients with Polycythemia vera suffered an ischemic stroke requires a proposed pattern of parameters including the test for JAK2V617F allelicloading and the calculation of Caprini score but not CHA2DS2-VASc score. Final results may provoke to change standard antithrombotic therapy in those patients towards its intensification due to pathogenetic featues of cancer-associated thrombosis.
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