Соціальні аспекти впровадження мультидисциплінарного підходу в процесі надання паліативної та хоспісної допомоги

В статье изложены результаты исследования внедрения мультидисциплинарного подхода в процессе оказания паллиативной помощи в Украине. Выяснено, что паллиативный (хосписный) уход является подходом, который улучшает качество жизни пациентов и их семей, сталкивающихся с проблемами, сопутствующими опасным для жизни заболеваниям. Выявлены особенности интерпретации понятия мультидисциплинарной команды в международных документах по паллиативной помощи (акцент на целях ее предоставления), и в отечественных нормативно-правовых актах (акцент на средствах ее реализации). Определены субъекты оказания паллиативной помощи в Украине. Установлены основные немедицинские (социальная, психологическая, духовная) составляющие ухода паллиативной помощи. Отмечено, что основными пользователями услуг в рамках паллиативной помощи могут выступать неизлечимые больные, родственники, а также работники паллиативных заведений в связи с высокой вероятностью профессионального выгорания.По результатам эмпирического исследования выявлено, что практика предоставления услуг паллиативной помощи на уровне Львова включает в себя функции социального работника, но не обеспечивает должности социального работника в составе рабочей группы. Установлено, что имеет место существенная нагрузка работников паллиативных заведений дополнительными функциями. Функции социального работника выполняются частично другими членами команды либо не выполняются вообще.The results of research of the multidisciplinary approach to the provision of the palliative care in Ukraine have been presented in the article. It has been found that the palliative (hospice) care improves the quality of life of patients (adults and children) and their families who face problems, related to life-threatening diseases. The peculiarities in the definition of a «multidisciplinary team» in Ukrainian law (the focus on means of implementation) and international documents on the palliative care (focused on the provision of care components) have been examined. The subjects of the palliative care in Ukraine are palliative institutions, specialized departments of medical institutions, mobile groups (services) of palliative care at home, centers for prevention and combating of AIDS, psychological services, territorial centers of social service for pensioners and lonely disabled people, NGOs and volunteers. The basic medical and non-medical (social, psychological, spiritual) care components of palliative care have been described in the article. The main service users of palliative care are not only terminally ill patients, but also their family members, relatives and palliative care institution employees, who experience high rates of professional burnout.The results of our empirical research have shown that the palliative care services in the city of Lviv include the functions of social workers, though no social worker positions exists in the service providing working groups. Instead, the functions of the social worker in this area are handled either by other team members (e.g. a chief doctor or other medical personnel, psychologist, priest, etc.), or professionals who do not belong to the service team (mostly psychologist). In some cases most part of the functions of the social worker are not delivered at all. The main social worker’s functions while implementing the social component of the palliative care may include the conduction of self-help groups for the terminally ill and their relatives, management of a client’s case, drawing up an individual work plan with the client and his/her family, basic legal counseling, provision of the supervision for members of the multidisciplinary team, establishment of contacts with other specialists, conduction of measures to prevent burnout, development of educational and leisure programs for children of different ages with different illnesses, training for teachers how to work with terminally ill children, development of leisure programs for the elderly (taking into account their age and physical condition), training for practitioners to provide these services, research and development of new programs in order to improve social services in the palliative care, establishment of networks with other social organizations, search for partners, grants, and training of clergy to work in palliative care.У статті викладено результати дослідження впровадження мультидисциплінарного підходу в процесі надання паліативної допомоги в Україні. З’ясовано, що паліативний (хоспісний) догляд є підходом, який покращує якість життя пацієнтів (дорослих і дітей) і їх сімей, які стикаються з проблемами, супутніми небезпечним для життя захворювань. Виявлено особливості тлумачення поняття мультидисциплінарної команди у міжнародних документах з паліативної допомоги (акцент на меті її надання) та у вітчизняних нормативно-правових актах (акцент на засобах її реалізації). Визначено суб’єкти надання паліативної допомоги в Україні. Встановлено основні немедичні (соціальна, психологічна, духовна) складові паліативної допомоги. Зазначено, що основними користувачами послуг у рамках паліативної допомоги можуть виступати як самі невиліковні хворі, так і їхні родичі, а також самі працівники паліативних закладів у зв’язку з високою ймовірністю професійного вигоряння.За результатами емпіричного дослідження виявлено, що практика надання послуг паліативної допомоги на рівні Львова включає у себе функції соціального працівника, але не забезпечує посади соціального працівника у складі робочої групи. Встановлено, що має місце суттєве навантаження працівників паліативних закладів додатковими функціями. Відповідно, функції соціального працівника у цій сфері виконуються частково іншими членами команди або не виконуються взагалі

A New Approach for Split Renal Function Assessment Based on 3D-Models Generated from Contrast-enhanced Multi-slice Computed Tomography (Msct) Scans and Mathematical Analysis: A Pilot Study

Introduction: Instrumental methods of examination may alter the course of treatment and patients’ management: from minimally invasive nephron-sparing procedures to radical operations. Objective:to present preliminary data on split kidney function assessment (in a kidney volume, e.g. segment) in patients with urological diseases.Materials and methods: A prospective study was launched in aResearch Institute for Uronephrology and Reproductive Health from November, 2015 to February, 2017. 31 patients were enrolled into the study: 15 with stone kidney disease, 2 with kidney anomalies, 14 with renal tumors. Contrast-enhanced CT with 3D-models andmathematical analysis were performed in all patients. Correlation between CT-based and renal scintigraphy-based measures of split renal function was estimated. Results: CT-based methods for the calculation of split renal function with 3D-models showed correlation with renal scintigraphy (p<0.004, ttest). Conclusion: A new approach for split kidney function assessment based on contrast-enhanced CT with 3D-models and mathematical analysis allows for both acquiring detailed data on clinical anatomy and evaluation of renal function to promote preoperative decision-making

Cytokinesproduction by blood immune cells in patients of different age groups with invasive ductal carcinoma of no special type and lymphatic metastases

The aim of this study was to evaluate production of cytokines by the blood immune cells in patients of different age groups with invasive non-specified type mammary ductal carcinoma, with or without metastases. Production of cytokines by periphery blood immunocompetent cells, either spontaneous and stimulated with polyclonal activators, was assessed in 82 patients with invasive mammary ductal carcinoma. The concentrations of IL-6, IL-8, IL-10, IL-17, IL-18, IL-1p, IL-1ra, TNFa, IFNy, G-CSF, GM-CSF, VEGF и MCP-1 were determined by solid-phase enzyme-linked immunosorbent assay. The patients were divided into 2 age groups: the first group consisted of 48 patients from 45 to 60 years old; the second group consisted of 34 older patients (61 to 75 years old). Metastases in local lymph nodes were documented in twenty patients from the first group and nine patients from the second group. The younger patients (45-60 years old) with metastases in local lymph nodes showed higher polyclonal activation index of IL-4 and IL-1ra production, when compared to the patients without lymphatic metastases. As for the older patients (61 to 75 years old), their polyclonal activation index of IL-6, IL-8, IL-1ra, G-CFS, GM-CSF production was significantly lower in cases of local lymph nodes metastases. The latter was due to higher level of spontaneous production, which suppressed the influence of polyclonal activators. The index of polyclonal activation upon production of cytokines in patients with lymphatic metastases was shown to be significantly higher for the age group of 45 to 60 years than in the age group of 61 to 75 years old. This fact suggested a highly stimulating effect of polyclonal activators in patients younger than 60 years. It was found that correlation between the index of polyclonal activation of cytokine production, and the indexes of ER, PR, HER2/NEU and Ki-67 receptor expression, which are used for the determination of molecular genetic subtype of the tumor, differ significantly for the distinct age groups

Поиск протеомных маркеров рака молочной железы в составе суммарных экзосом крови

To improve early detection of cancer, search for tumor markers in biological fluids is of great importance. A significant portion of exosomes is associated with the surface of blood cells, however, the protein spectrum of such exosomes has not been previously studied. The use of total blood exosomes (plasma exosomes and exosomes associated with the surface of blood cells) can not only significantly increase the specificity and sensitivity of existing methods, but also suggest new tumor markers for liquid biopsy.Objective. Search for candidate protein tumor markers of breast cancer by comparing 2D-proteomic maps of total blood exosomes of healthy females (HFs) and breast cancer patients (BCPs).Methods. Exosomes were isolated from plasma and total blood of HFs and BCPs by ultrafiltration followed by ultracentrifugation and were characterized using transmission electron microscopy (TEM) and immunocytochemistry. Protein concentration in exosomes was determined using the NanoOrange Protein Quantitation kit (Invitrogen) commercial kit. Proteomes of exosomes were studied using 2d electrophoresis followed by protein identification by mass spectrometry.Results. Highly purified samples of vesicles from plasma and total blood of no more than 100 nm in size were obtained, on the surface of which markers specific for exosomes were detected by monoclonal antibodies CD9. A comparative analysis of the proteomic maps of exosomal proteins of the HFs and BCPs obtained by 2D-electrophoresis allowed us to establish significant differences in the expression level and protein set in normal and pathological conditions. The 11 proteomic markers of breast cancer were identified by the peptide fingerprint method, of which LRG и у-chain FGB were detected in the composition of exosomes for the first time (according to the Exocarta database). Using MALDI-TOF mass spectrometry, 99 proteins were identified in the exosome preparations of the blood of HFs and BCPs, of which 35% were detected in the composition of the exosomes for the first time (according to the Exocarta database). 17 (53%) proteins associated with breast cancer were detected in total blood exosomes of cancer patients.Conclusion. The results obtained indicate that total blood exosomes are a promising source of diagnostic material for the search for proteomic markers of breast cancer. The identified proteomic tumor markers require further validation.Актуальность. Актуальной задачей повышения эффективности ранней диагностики онкологических заболеваний является поиск высокоспецифичных опухолевых маркеров в биологических жидкостях организма. Значительная часть экзосом ассоциирована с поверхностью форменных элементов крови, однако белковый спектр таких экзосом ранее не исследовался. использование суммарных экзосом крови (экзосом плазмы и экзосом, ассоциированных с поверхностью клеток крови) может не только значительно повысить специфичность и чувствительность существующих методов, но и выявить новые онкомаркеры для жидкостной биопсии.Цель работы - поиск кандидатных белковых онкомаркеров рака молочной железы (РМЖ) путем сравнения 2D-протеомных карт суммарных экзосом крови здоровых женщин и больных РМЖ.Материал и методы. Экзосомы выделены из крови здоровых женщин и больных РМЖ методом ультрафильтрации с последующим ультрацентрифугированием и охарактеризованы при помощи трансмиссионной электронной микроскопии и иммуноцитохимии. Концентрацию белка в экзосомах определяли при помощи коммерческого набора NanoOrange Protein Quantitation kit (Invitrogen). Протеом экзосом исследован с помощью 2D-электрофореза с последующей идентификацией белков методом масс-спектрометрии.Результаты. Получены высокоочищенные препараты микровезикул суммарной крови размером не более 100 нм, на поверхности которых иммуноцитохимически были выявлены специфические для экзосом маркеры (CD63, CD9 и CD24). Сравнительный анализ протеомных карт экзосомальных белков здоровых женщин и больных РМЖ, полученных с помощью 2D-электрофореза, позволил установить значимые различия в уровне экспрессии и наборе белков в норме и патологии. Методом пептидного фингерпринта идентифицировано 11 перспективных протеомных маркеров РМЖ, из них LRG и у-цепь FGB выявлены в составе экзосом впервые (согласно базе Exocarta). Методом MALDI-TOF масс-спектрометрии идентифицировано 99 белков в препаратах экзосом крови здоровых женщин и больных РМЖ, из них 35 % выявлены в составе экзосом впервые (согласно базе Exocarta). В составе суммарных экзосом крови онкологических больных выявлено 17 (53 %) белков, ассоциированных с РМЖ.Заключение. Полученные результаты свидетельствуют о том, что суммарные экзосомы крови являются перспективным источником диагностического материала для поиска протеомных маркеров РМЖ. идентифицированные протеомные онкомаркеры в их составе требуют дальнейшей валидации

Search for breast cancer proteomic markers in total blood exosomes

To improve early detection of cancer, search for tumor markers in biological fluids is of great importance. A significant portion of exosomes is associated with the surface of blood cells, however, the protein spectrum of such exosomes has not been previously studied. The use of total blood exosomes (plasma exosomes and exosomes associated with the surface of blood cells) can not only significantly increase the specificity and sensitivity of existing methods, but also suggest new tumor markers for liquid biopsy.Objective. Search for candidate protein tumor markers of breast cancer by comparing 2D-proteomic maps of total blood exosomes of healthy females (HFs) and breast cancer patients (BCPs).Methods. Exosomes were isolated from plasma and total blood of HFs and BCPs by ultrafiltration followed by ultracentrifugation and were characterized using transmission electron microscopy (TEM) and immunocytochemistry. Protein concentration in exosomes was determined using the NanoOrange Protein Quantitation kit (Invitrogen) commercial kit. Proteomes of exosomes were studied using 2d electrophoresis followed by protein identification by mass spectrometry.Results. Highly purified samples of vesicles from plasma and total blood of no more than 100 nm in size were obtained, on the surface of which markers specific for exosomes were detected by monoclonal antibodies CD9. A comparative analysis of the proteomic maps of exosomal proteins of the HFs and BCPs obtained by 2D-electrophoresis allowed us to establish significant differences in the expression level and protein set in normal and pathological conditions. The 11 proteomic markers of breast cancer were identified by the peptide fingerprint method, of which LRG и у-chain FGB were detected in the composition of exosomes for the first time (according to the Exocarta database). Using MALDI-TOF mass spectrometry, 99 proteins were identified in the exosome preparations of the blood of HFs and BCPs, of which 35% were detected in the composition of the exosomes for the first time (according to the Exocarta database). 17 (53%) proteins associated with breast cancer were detected in total blood exosomes of cancer patients.Conclusion. The results obtained indicate that total blood exosomes are a promising source of diagnostic material for the search for proteomic markers of breast cancer. The identified proteomic tumor markers require further validation

Tissue-engineered substitution urethroplasty based on decellularized vascular matrix and autologous cells of the buccal mucosa: the first experience

Urethral strictures and anomalies remain a challenging urological problem. Reconstructive plastic surgery has been shown to be the most effective way to treat them. There are two main types of urethroplasty: anastomosis (anastomotic urethroplasty) and expansion of the urethral lumen using of flaps and grafts (substitution urethroplasty). Currently the ideal material for substitution urethroplasty does not exist. Tissue engineering of the urethra seems to be one of the most promising approaches to address this problem. Various tissues-engineering techniques were proposed for substitution urethroplasty. In this study, tissue-engineering design was based on the decellularized cadaveric arterial wall. The study results demonstrated the feasibility of creating stable tissue-engineered structures with autologous cultured epithelial cells of the buccal mucosa and decellularized matrix from human cadaveric arterial wall (DMCAW). There was a complete engraftment of tissue-engineering design based on DMCAW and buccal mucosa cells, used for substitution urethroplasty in a patient with the bulbar urethral stricture. Postoperatively (within 4 months after surgery) no complications and/or adverse events were observed. However, in the late postoperative period (12 months) there was recurrence of urethral stricture in the middle of the tissue-engineering design and the native urethra that warranted another surgery. Tissue-engineering design based on DMCAW and autologous buccal mucosa is safe as a material for substitution urethroplasty. Further research is required to ascertain the effectiveness of the method.7 page(s

Experimental validation of the developing a matrix based on decellularized vascular wall for subsequent substitution urethroplasty

Urethral strictures are urgent urological problem. Anastomotic and substitution urethroplasty are the most effective treatments. For substitution urethroplasty, buccal mucosa is most often used. There are the following difficulties associated with the substitution urethroplasty: complications in the donor area, the lack of tissue for substitution, an additional incision, and increased timing of surgery due to the need to obtain a flap or graft. Tissue engineering can be useful in solving the above problems. Tissue engineering involves the use a matrix without cells and matrix with one or more types of cells (tissue-engineering designs). In our study we have evaluated the ability to create a matrix for the substitution urethroplasty in animal experiments. The decellularized cadaveric arterial wall was used as a matrix. Decellularization was performed using enzymatic method. At the first stage, we transplanted matrix fragments in interscapular region in rats. An extremely weak bioactivity dof decellularized matrix of cadaveric arterial wall (DMCAW) due to the low immunogenicity of the material was revealed. Thus resorption of DMCAW was quite slow (60-90 days). At the second stage, in an experiment on rabbits, substitution urethroplasty using tubular DMCAW was successfully performed. Intraoperative urethral defect up to 1.8 cm was created, which was replaced by a tubular DMCAW. The use of this type of matrix has showed good structural and functional results: urethral strictures did not arise, the rejection of the matrix was not observed. A slow degradation of the matrix and progressive epithelialization of onnective tissue capsule were revealed. Decellularized matrix based on cadaveric arterial wall can be considered as a material for substitution urethroplasty.6 page(s

Корреляция 3D-морфотопометрических характеристик опухоли почки с ее гистологическим строением

Aim. To assess the correlation between clinical characteristics (sex, age, and maximum tumor size), 3D morphometric characteristics of renal lesions obtained through processing of multispiral computed tomography data, and renal tumor histology.Materials and methods. Evaluation of kidney tumor malignancy on the basis of comparative analysis of primarily morphometric characteristics of the lesion obtained through processing of multispiral computed tomography data and histological tumor structure is presented. Data of 308 patients (175 (56.8 %) males and 133 (43.2 %) females) with unilateral renal tumors were analyzed.Results. Multivariable analysis showed that malignancy of kidney tumor is associated with sex (male), location in the middle segment, tumor size, tumor shape (spherical with conical base) (24.8 %), while mushroom-like lesion shape was more common in benign tumors (35.2 %). In univariate models, only two variables were statistically significant predictors: patient sex and tumor shape.Conclusion. The developed logistic model based on analysis of such predictors as sex and kidney tumor shape has a high percentage (87.6 %) of correct predictions of tumor histological structure.Цель исследования – оценить корреляцию общих показателей (пол, возраст, максимальный размер опухоли), 3D-морфотопометрических характеристик опухолевого узла почки, полученных при постпроцессинговой обработке данных мультиспиральной компьютерной томографии, с характером гистологического строения новообразования.Материалы и методы. Представлен опыт оценки злокачественности опухоли почки на основании сравнительного анализа преимущественно морфотопометрических характеристик новообразования почки, полученных при постпроцессинговой обработке данных мультиспиральной компьютерной томографии, и гистологического строения опухоли. Проанализированы данные 308 пациентов (175 (56,8 %) мужчин и 133 (43,2 %) женщины) с односторонней опухолью почки.Результаты. Многофакторный анализ показал, что злокачественность новообразования почки ассоциирована с полом (мужским), локализацией в среднем сегменте почки, размером опухоли, формой (шаровидной с конусовидным основанием) (24,8 %), в то время как грибовидная форма опухолевого узла наиболее часто наблюдалась при доброкачественных новообразованиях (35,2 %). В однофакторных моделях в качестве статистически значимых предикторов показали себя только 2 фактора – пол пациента и форма опухоли.Заключение. Полученная логистическая модель, основанная на анализе таких предикторов, как пол и форма новообразования почки, имеет высокий процент (87,6 %) корректных предсказаний его гистологического строения