Corporate and industrial form of the organization of health care

In recent history, the functions and forms of health care remain insufficiently analyzed, despite the fact that the incentives invested in medicine determine not only the volume and structure of medical care, but also the reasons for its provision, which are becoming wider, and costs are increasing. The COVID-19 pandemic, as well as the global geopolitical, ideological and economic crisis that emerged in 2022, will require changes in both the structure and economics of the health care system in accordance with its main mission – providing conditions in which people can be healthy.The aim of this article is to analyze the concept of a modern health care system.Materials and methods. Statistical materials of the Russian Research Institute of Health, methods of content analysis, analytical materials of Russian and foreign researchers, including those posted on the Internet, were used.Results. The materials presented in the article allow us to talk about the emergence of a new form of healthcare organization during the life of just one generation of people, where economic incentives are dominant, characteristic of the market and commodity production, the vector of development of which is largely determined by the interests of international financial institutions, clinical corporations, as well as enterprises, manufacturing medical and pharmaceutical products. The expansion of the resource base in this model can occur by attributing epidemic character to certain diseases, as well as by turning social phenomena into medical problems. Therefore, there is always a shortage of resources, and it is not possible to eliminate it without changing the paradigm of the development of the industry and qualified management.Findings. Radical changes in the structure and economics of health care need to be made in line with the industry’s core mission of providing conditions in which people can stay healthy. The basis of these changes is the displacement of market self-regulation and the genesis of a mixed public-private (hybrid) healthcare economy

Чувствительность барорецепторов и состояние автономной нервной системы у пациентов с хроническими нарушениями сознания

Purpose of the study: to examine sensibility of baroreceptors and the autonomic nervous in the passive orthostatic test in patients with chronic impairment of consciousness due to severe brain damage and determine their role in the rehabilitation process.Materials and methods. The study included 30 patients with long-term impairment of consciousness due to severe brain damage (group 1), 10 of them being in the vegetative state (VS) and 20 being in the minimally conscious state (MCS). Craniocerebral trauma was the main cause of severe damage in that group (53% of patients). The comparison group included 24 patients with focal neurological symptoms caused predominantly — 79.2% of cases — by cerebrovascular disorders (group 2). The control group (group 3) consisted of 22 healthy volunteers of a comparable age. All measurements were done with the help of a Task Force Monitor 1030i (CNSystem, Austria) in the course of passive orthostatic test at 0°–30°–60°–0°. Changes in the power of low-frequency (LFS) and highfrequency spectrum (HFS) of heart rate variability and baroreceptors sensibility (BRS) were analyzed. Statistical analysis was carried out using Statistica-10 software. Significance of inter-group differences on unrelated samples was determined by the Mann–Whitney U-test. Differences between groups were considered significant at P 0.05.Results. Maximal background values of BRS were found in the control group. In group 1 and 2 patients, considerable decrease of that index was noted, which was proportional to the brain damage severity. Similar dynamics was observed for the indices of autonomic nervous system sensibility (LFS and HFS). The main trend of orthostatic changes of BRS, LFS, and HFS was characterized by progressive decrease of the indices with increase of the patients’ angle of tilting and their return to the baseline level after the patients were put back into the horizontal position. 4 patients of group 1 (14%) displayed signs of orthostatic disorders upon tilting to 30°: in 3 cases, orthostatic hypotension was observed, and in one case the postural orthostatic tachycardia syndrome (POTS) was diagnosed. Those patients differed by lower BRS and higher sympathetic system activity (LFS) vs. the same indices of other patients in that group.Conclusion. Patients with chronic impairment of consciousness during the post-comatose period after a severe brain damage display a significant decrease of baroreceptors sensibility and autonomic nervous system disorders manifesting in significantly lower activity of the sympathetic and parasympathetic systems. The prominence of such disorders is associated with brain damage severity. Their risk of developing orthostatic hypotension during tilting towards a vertical position is higher in patients who have lower baroreceptors sensibility, and this should be taken into account beginning the process of their verticalization.Цель исследования: изучить чувствительность барорецепторов и автономной нервной системы при пассивной ортостатической пробе у пациентов с хроническими нарушениями сознания вследствие тяжелых повреждений головного мозга и определить их роль в реабилитационном процессе.Материалы и методы. В исследование включили 30 пациентов с длительными нарушениями сознания, вызванными тяжелыми повреждениями головного мозга (группа 1), 10 из которых были в вегетативном состоянии (ВС) и 20 — с синдромом малого сознания (СМС). Основной причиной тяжелых повреждений была черепно-мозговая травма (53% пациентов этой группы). В группу сравнения вошли 24 пациента с очаговой неврологической симптоматикой, основной причиной которой в 79,2% случаев были нарушения мозгового кровообращения (группа 2). Контрольную группу (группа 3) составили 22 здоровых добровольца сопоставимого возраста. Все измерения проводили с помощью монитора Task Force Monitor 1030i (CNSystem, Австрия) в процессе пассивной ортостатической пробы 0°–30°–60°–0°. Провели анализ изменений показателей мощности низкочастотного (НЧС) и высокочастотного спектров (ВЧС) вариабельности сердечного ритма и чувствительности барорецепторов (ЧБР). Статистический анализ провели с помощью пакета статистических программ «Statistica-10». Значимость межгрупповых различий несвязанных выборок определяли расчетом критерия Манна Уитни (Mann–Whitney U-test). Достоверными считали различия при достижении уровня статистической значимости p 0,05.Результаты. Максимальные фоновые значения ЧБР выявили в контрольной группе. У пациентов 1 и 2 групп отмечали значительное снижение этого показателя, пропорциональное тяжести повреждений головного мозга. Аналогичную динамику имели показатели чувствительности автономной нервной системы (НЧС и ВЧС). Основной тренд ортостатических изменений ЧБР, НЧС, ВЧС характеризовался прогрессивным снижением этих показателей при увеличивающемся угле наклона пациентов и с восстановлением их до исходного уровня после возврата пациентов в горизонтальное положение. У 4 пациентов группы 1 (14%) при выполнении наклона на 30° появились признаки ортостатических нарушений: в 3 случаях наблюдали ортостатическую гипотензию и в одном — синдром постуральной ортостатической тахикардии (СПОТ). Отличием этих пациентов были более низкая ЧБР и более высокие показатели активности симпатической системы (НЧС) по сравнению с показателями других пациентов данной группы.Заключение. У пациентов с хроническими нарушениями сознания в посткоматозном периоде после тяжелых повреждений головного мозга наблюдаются значительное снижение чувствительности барорецепторов и нарушения автономной нервной системы, выражающиеся в значительном снижении активности симпатической и парасимпатической систем. Степень этих нарушений ассоциирована с тяжестью повреждений головного мозга. Риск развития ортостатической гипотензии при вертикализации выше у пациентов с более низкой чувствительностью барорецепторов, что необходимо учитывать в начале процесса их вертикализации

ПРОБЛЕМЫ ОКАЗАНИЯ МЕДИЦИНСКОЙ ПОМОЩИ В РАМКАХ КЛИНИЧЕСКОЙ АПРОБАЦИИ

In order to strengthen the state support of national medical science and to improve the effectiveness of the use of scientific and technological potential of federal clinics currently a legal framework is created for medical care delivery within clinical testing of methods of prevention, diagnostics, treatment and rehabilitation. The article considers the problems of medical care organization within clinical testing. It is shown that the priority areas of rulemaking in this sphere are the creation of viable mechanisms for assessment the effectiveness of new technologies as well as the security of medical care provided to patients who are selected and hospitalized to institutions and research centers according to the themes of scientific researches.В целях усиления государственной поддержки отечественной медицинской науки и повышения эффективности использования научно-технического потенциала федеральных клиник в настоящее время создана правовая база для оказания медицинской помощи в рамках клинической апробации методов профилактики, диагностики, лечения и реабилитации. В статье рассматриваются проблемы организации медицинской помощи в рамках клинической апробации. Показано, что приоритетными направлениями нормотворчества в этой сфере являются создание действенных механизмов оценки результативности новых технологий, а также безопасности медицинской помощи, оказываемой пациентам, отобранным и госпитализированным в институты и научные центры по тематике научных исследований

Возможности электромиографии в прогнозировании восстановления при идиопатической нейропатии лицевого нерва

In the article we present the results of the retrospective clinico-electrophysiological analysis of 182 patients suffering from the idiopathic neuropathy of the facial nerve (Bell`s palsy). The comparison of the most common electromyographical (ENMG) predictors of outcomes was made. It was demonstrated that the most sensitive method in the acutest period (less then 5 days) is the level of excitability of the nerve, in the acute period (less then 14 days) – estimation of M-answer amplitude loss, and from the 21st day – the presence of denervation in muscles. The most specific electromyographical approach to estimate the therapy efficiency is an analysis of the M-answer amplitude and latency. In conclusion, neurologists have the possibility to predict the outcome and to control the therapy efficiency in any period of the disease. The correlation dynamics ÈNMG sensitivity settings – NLN on different dates can be used to determine the volume of ÈNMG – the NLN study depending on the timing for the treatment of patients.Представлены результаты ретроспективного клинико-электромиографического (ЭНМГ) анализа 182 пациентов с идиопатической нейропатией лицевого нерва (НЛН). Проведено сравнение наиболее часто исследуемых ЭНМГ-параметров для определения благоприятного и неблагоприятного прогнозов восстановления. Выявлено, что наиболее чувствительным ЭНМГ-параметром в острейшем периоде (до 5 дней) НЛН является определение порога вызывания моторного ответа и исследование мигательного рефлекса; в остром периоде (от 10 до 14 дней) – измерение процентного соотношения падения амплитуды М-ответа пораженной стороны по отношению к здоровой; начиная с 21 дня – наличие неврогенных изменений в мышцах. На основании полученных данных предлагается наиболее оптимальный объем ЭНМГ-исследования при идиопатической НЛН на разных сроках заболевания

Острые и хронические дизиммунные полиневропатии в условиях пандемии COVID-19: патогенез, особенности клинической картины, диагностики и терапии (обзор литературы)

Dysimmune polyneuropathies are the etiologically heterogeneous group of diseases with autoimmune damage to the peripheral nervous system. The rarity of these diseases doesn’t exclude the possibility of their development or exacerbation in patients infected with SARS‑CoV‑2, which will require timely differential diagnosis and urgent specific therapy. The article summarizes current information on the mechanisms of development, clinical features, diagnosis and management of acute and chronic dysimmune polyneuropathies in the context of the COVID‑19 pandemic.Дизиммунные полиневропатии представляют собой этиологически гетерогенную группу заболеваний с аутоиммунным поражением периферической нервной системы. Редкость данных заболеваний не исключает возможности их развития или обострения у инфицированных SARS‑CoV‑2 пациентов, что, в свою очередь, потребует проведения своевременной дифференциальной диагностики и неотложной интенсивной и специфической терапии. В статье обобщены актуальные на данный момент сведения, касающиеся механизмов развития, особенностей клинической картины, диагностики и тактики ведения острых и хронических дизиммунных полиневропатий в условиях пандемии COVID‑19

Orthostatic Hemodynamic Changes in Brain Damage

Aim: to study orthostatic hemodynamic changes in patients with chronic disorders of consciousness after critical brain damage.Materials and methods. We studied 30 patients (10 women and 20 men) with chronic disorders of consciousness after severe brain damage aged 45±7 years, 10 of which were in the vegetative state (VS) and 20 had the minimally conscious state (MCS). The main causes of brain damage were traumatic brain injury (53% of patients) and cerebrovascular accidents (CVA) (23.3%). The rest of the patients had posthypoxic encephalopathy or were after brain tumor removal surgery. Passive orthostatic test (POT) 0° to 60° to 0° was performed using an electrically driven tilt table (Vario Line). Hemodynamic monitoring during the verticalization was done using a non-invasive oscillometric recording of blood pressure on the brachial artery, stroke volume (SV) and cardiac minute output (CMO) were measured by impedance cardiography with the multifunctional «Task Force Monitor 3010i» (CNSystem, Austria). Data were statistically analyzed using the Statistica 10 software package.Results. Orthostatic hemodynamic stability was found in 26 out of 30 patients with chronic disorders of consciousness after critical brain damage. It was manifested by stable systolic blood pressure (SBP) in tilted orthostatic and horizontal position (120.7±2.2 and 121.1±3.6 mmHg, respectively, P>0.05). Orthostatic hypotension was observed in 3 patients and postural tachycardia syndrome (PTS) in one patient. We compared orthostatic hemodynamic changes in the studied cohort versus published data on orthostatic hemodynamic changes uncluding POT revealed in patients with severe brain damage examined before and after brain death.Conclusion. Orthostatic stability of blood circulation can be maintained for a short period of time in patients surviving after critical diffuse brain damage associated with chronic disorders of consciousness. Critical brain damage resulting in brain death associates with a significant reduction of all hemodynamic parameters and severe orthostatic hypotension with restoration of initial blood pressure values when the patient is returned to the horizontal position

Electromyography: prognosis and evaluation of the efficiency of therapy for Bell's palsy

The paper presents the results of clinical and electromyographic studies in 182 patients with idiopathic facial neuropathy (BellXs palsy). The most commonly studied parameters of electroneuromyography (ENMG) were compared to determine a good or poor prognosis for recovery. The most sensitive parameters were shown to be nerve excitability threshold in the acutest period (up to 5 days), M-response amplitude fall ratio on the affected and intact sides and reversibility of impaired irritability in the acute period (on days 10 to 14), and muscle denervation changes starting on day 21. The most sensitive ENMG parameters for the evaluation of the efficiency of performed therapy were changes in M-response amplitude and latency. Thus, ENMG can estimate disease prognosis and monitor treatment efficiency

Sensitivity of the Baroreceptors and the State of the Autonomic Nervous System in Patients with Chronic Impairment of Consciousness Due to Severe Brain Damage

Purpose of the study: to examine sensibility of baroreceptors and the autonomic nervous in the passive orthostatic test in patients with chronic impairment of consciousness due to severe brain damage and determine their role in the rehabilitation process.Materials and methods. The study included 30 patients with long-term impairment of consciousness due to severe brain damage (group 1), 10 of them being in the vegetative state (VS) and 20 being in the minimally conscious state (MCS). Craniocerebral trauma was the main cause of severe damage in that group (53% of patients). The comparison group included 24 patients with focal neurological symptoms caused predominantly — 79.2% of cases — by cerebrovascular disorders (group 2). The control group (group 3) consisted of 22 healthy volunteers of a comparable age. All measurements were done with the help of a Task Force Monitor 1030i (CNSystem, Austria) in the course of passive orthostatic test at 0°–30°–60°–0°. Changes in the power of low-frequency (LFS) and highfrequency spectrum (HFS) of heart rate variability and baroreceptors sensibility (BRS) were analyzed. Statistical analysis was carried out using Statistica-10 software. Significance of inter-group differences on unrelated samples was determined by the Mann–Whitney U-test. Differences between groups were considered significant at P 0.05.Results. Maximal background values of BRS were found in the control group. In group 1 and 2 patients, considerable decrease of that index was noted, which was proportional to the brain damage severity. Similar dynamics was observed for the indices of autonomic nervous system sensibility (LFS and HFS). The main trend of orthostatic changes of BRS, LFS, and HFS was characterized by progressive decrease of the indices with increase of the patients’ angle of tilting and their return to the baseline level after the patients were put back into the horizontal position. 4 patients of group 1 (14%) displayed signs of orthostatic disorders upon tilting to 30°: in 3 cases, orthostatic hypotension was observed, and in one case the postural orthostatic tachycardia syndrome (POTS) was diagnosed. Those patients differed by lower BRS and higher sympathetic system activity (LFS) vs. the same indices of other patients in that group.Conclusion. Patients with chronic impairment of consciousness during the post-comatose period after a severe brain damage display a significant decrease of baroreceptors sensibility and autonomic nervous system disorders manifesting in significantly lower activity of the sympathetic and parasympathetic systems. The prominence of such disorders is associated with brain damage severity. Their risk of developing orthostatic hypotension during tilting towards a vertical position is higher in patients who have lower baroreceptors sensibility, and this should be taken into account beginning the process of their verticalization