ОЦЕНКА ТРУДОСПОСОБНОСТИ ПАЦИЕНТОВ, ПОДВЕРГШИХСЯ КОРОНАРНОМУ ШУНТИРОВАНИЮ

The main objectives of coronary artery bypass grafting (CABG) are restoration of patients’ normal functional status, improvement of life quality, as well as resumption of professional activity. A patient’s return to work is perceived as a marker of rehabilitation’s efficacy. However despite the improvement of clinical state of majority of operated patients, life quality and markers of labour ability in part of patients after CABG are not improved. The percentage of patients returning to work differs all over the world due to many factors – such as differences in patients’ insurance systems, labor market conditions, economic situation in a country. In Russia the marker of returning to work after CABG is extremely low, it has serious fluctuations in the different regions and is not determined by objective criteria. The provided data indicate that there are still no common approaches to the assessment of patients’ ability to return to work after CABG. In the present research we systemize the indications for performing medical and social assessment after CABG taking into account the regulatory framework.Основными задачами операции коронарного шунтирования (КШ) являются восстановление нормального функционального состояния пациентов, повышение качества жизни, а также возобновление профессиональной деятельности. Возврат пациента на работу воспринимается как маркер эффективности реабилитации. Однако, несмотря на улучшение клинического состояния большинства оперированных, качество жизни и показатели трудоспособности после КШ у части больных не улучшаются. Процент возвращения пациентов к труду различается по всему миру в силу многих факторов, таких как: различия систем страхования пациентов, условия на рынке труда, экономическая ситуация в стране. В России показатель возвращения к труду после перенесенного КШ крайне низкий, имеет серьезные колебания в различных регионах и не определяется объективными критериями. Представленные данные свидетельствуют о том, что до сих пор отсутствуют единые подходы к оценке возможности возврата к труду пациентов после КШ. В данной работе проведена систематизация показаний направления на МСЭ после КШ c учетом нормативно-правовой базы

РЕКОМЕНДАЦИИ, ОСНОВАННЫЕ НА МНЕНИИ ЭКСПЕРТОВ. ПОЗИЦИЯ РОССИЙСКИХ ВРАЧЕЙ

The article presents the standpoint of Russian physicians (obtained by means of survey of 13 expert clinician cardiologists of a Russian clinic) on the recommendations ofAmericanAcademyof Family Physicians based on expert’s opinion. According to the results of the survey it is noted that a consensus was reached in 8 out of 12 recommendations, and upon one of the recommendations all Russian physicians participating in the survey disagreed. Thereby it is shown that the recommendations is only a basis for decision making and in each particular case a physician makes a decision based on the clinical features and the current situation. Moreover, our research testifies that perhaps in the Russian Federation it is also needed to use not just blind copying of even the most advanced recommendations and quite formal (but not formalized) discussion of these recommendations by specialists. It is also necessary to update the recommendations taking into account the new evidences (results of methodologically correct researches) as well as reasonability of participating in discussion and considering the opinions of representatives and scientific communities, practitioners, representatives of different medical organizations, governing bodies of the health care system and insurance companies. В статье представлена позиция российских врачей, полученная путем анкетирования 13 экспертов-клиницистов кардиологов российской клиники, на рекомендации American Academy of Family Physicians, основанные на мнении экспертов. По результатам анкетирования отмечено, что консенсус достигнут по 8 из 12 рекомендаций, а по одной из позиций все российские врачи, участвующие в опросе, выразили несогласие. Тем самым показано, что рекомендации – это только основа для принятия решений, а в каждом конкретном случае врач принимает решение исходя из клинических особенностей и сложившейся ситуации. Кроме того, наше исследование свидетельствует, что, вероятно, и в РФ необходимо использовать не просто слепое копирование пусть даже самых современных рекомендаций и достаточно формальное (но не формализованное) обсуждение этих рекомендаций специалистами. Необходимо и обновление рекомендаций с учетом новых доказательств (результатов методологически корректных исследований), а также целесообразности участия в обсуждении и учета мнения представителей и научных сообществ, практикующих врачей, представителей различных медицинских организаций, руководящих органов системы здравоохранения и страховых компаний.

АОРТИТ-НЕМОЕ ПРОЯВЛЕНИЕ, СЕРЬЕЗНЫЕ ПОСЛЕДСТВИЯ

The article presents a clinical case of delayed diagnosis of extra-articular manifestations of ankylosing spondylitis and aortitis. 15 years after the onset of symptoms, this diagnosis was established when the irreversible joint damage and cardiovascular complications were present, namely extra-articular manufestatations of aortitis, i.e. ascending aortic extension and the total aortic insufficiency. This clinical case presents a successful surgical treatment of acquired aortic valve disease. The patient underwent the Bentall-de Bono procedure, including aortic valve replacement and plasty of the ascending aorta with a valved conduit “MedEng-23” (MedEng, Russia). Moreover, the current article highlights the problem of selecting optimal medical therapy (therapy for ankylosing spondylitis and anticoagulants) due to ad-verse drug interactions. The reasons for delayed diagnosis were analyzed. Unfortunately, the main reasons are subjec-tive, i.e. general physicians (non-rheumatologists) do not know well clinical signs and symptoms of this disease as well as imaging findings suggesting this diagnosis.В статье представлен клинический случай, де-монстрирующий запоздалую постановку диагноза: анкилозирующий спондилит с внескелетным про-явлением аортит. Данный диагноз был установлен спустя 15 лет от начала появления симптомов забо-левания и уже на стадии необратимых изменений как со стороны суставной системы, так и со стороны сердечно-сосудистой системы, когда проявилась клиника осложнения внескелетного поражения аортита, в виде расширения восходящего отдела аорты и тотальной аортальной недостаточности. В представленном клиническом примере проде-монстрировано успешное хирургическое лечение развившегося порока сердца протезирование аортального клапана и восходящего отдела аорты клапан содержащим кондуитом «Мединж-23»( ЗАО НПП «МедИнж»,Россия) (операция Бенталла-де Боно) и возникшие сложности в подборе медикаментозных препаратов (базисной терапии анкилозирующего спондилита и антикоагулянтов) вследствие неблагоприятного лекарственного взаимодействия. Проанализированы причины поздней постановки диагноза и основные из них, к сожалению, субъек-тивные незнание врачами других специальностей - «не ревматологов» клиники, рентгенодиагностики данного заболевания

ТРЕХЛЕТНИЕ РЕЗУЛЬТАТЫ МЕДИКАМЕНТОЗНОГО И ХИРУРГИЧЕСКОГО РЕПЕРФУЗИОННОГО ЛЕЧЕНИЯ ПАЦИЕНТОВ, ПЕРЕНЕСШИХ ТРОМБОЭМБОЛИЮ ЛЕГОЧНОЙ АРТЕРИИ: ИСХОДЫ, КЛИНИЧЕСКИЙ СТАТУС, СОСТОЯНИЕ ЛЕГОЧНОЙ ПЕРФУЗИИ

The purpose. To estimate hospital and three-year results of reperfusion treatment in pulmonary embolism (PE) patients.Methods. One-center prospective study included 30 patients with intermediate high-risk and high-risk acute PE that had indications for reperfusion: thrombolytic therapy (TLT) and / or surgical thrombectomy. The endpoints of the study in the hospital and long-term follow-up period were such unfavorable cardiovascular events as death, myocardial infarction, acute cerebrovascular accident / transient ischemic attack, re-PE.Results. It was shown that reperfusion treatment had satisfactory rates of hospital survival (97%), efficacy, with significant regression of clinical symptoms and pulmonary hypertension (from 56.93 ± 17.18 to 36.72 ± 14.47 mm Hg.). There was a significant decrease of tricuspid insufficiency (from 77% initially to 24% at the time of discharge) (p <0.05). After 3 years, the rate of fatal outcomes reached 33%, most of which occurred in the TLT group and was associated with re-PE. Fifty fife percent of the surviving patients had pulmonary hypertension, 15% had major or segmental perfusion defects according to perfusion lung scintigraphy (PSL) data.Conclusion. The presence of significant pulmonary perfusion defects according to the results of PSL in one out of seven surviving patients in more than half of the cases is likely to be a result of insufficiently frequent use of the surgical option of treatment in clinical practice. The high frequency of fatal outcomes in the long-term follow-up period, realized through re-PE, indicates insufficient compliance of patients to medical therapy. Цель. Оценить госпитальные и трехлетние результаты медикаментозного и хирургического реперфузионного лечения пациентов, перенесших ТЭЛА.Материалы и методы. В одноцентровое проспективное исследование вошло 30 пациентов с острой ТЭЛА промежуточного высокого и высокого риска, имевших показания к реперузионной терапии в объеме тромболитической терапии (ТЛТ) и/или хирургической тромбэктомии. Конечными точками исследования в госпитальном и отдаленном периоде наблюдения стали такие неблагоприятные кардиоваскулярные события, как смерть, инфаркт миокарда, острое нарушение мозгового кровообращения/транзиторная ишемическая атака, рецидив ТЭЛА.Результаты. Показано, что реперфузионное лечение имело удовлетворительные показатели госпитальной выживаемости (97%), эффективности, что проявилось в существенном регрессе клинических симптомов и значимом снижении выраженности легочной гипертензии (с 56,93±17,18 до 36,72±14,47 мм рт. ст.) со значимым уменьшением трикуспидальной недостаточности (с 77% исходно до 24% на момент выписки) (р<0,05). Спустя 3 года частота фатальных исходов достигла 33%, большинство из которых имело место в группе ТЛТ и было связано с рецидивом ТЭЛА. Среди выживших пациентов 55% имели проявления легочной гипертензии, 15% – крупные или сегментарные дефекты перфузии по данным перфузионной сцинтиграфии легких (ПСЛ).Заключение. Наличие значимых дефектов перфузии легки, по результатам ПСЛ, у каждого седьмого из выживших пациентов более чем в половине случаев, вероятно, может быть следствием недостаточно частого использования хирургической опции лечения в клинической практике. Высокая частота фатальных исходов в отдаленном периоде наблюдения, реализуемая посредством рецидива ТЭЛА, свидетельствует о недостаточной комплаентности пациентов к медикаментозной терапии.

Immunoglobulin, glucocorticoid, or combination therapy for multisystem inflammatory syndrome in children: a propensity-weighted cohort study

Background: Multisystem inflammatory syndrome in children (MIS-C), a hyperinflammatory condition associated with SARS-CoV-2 infection, has emerged as a serious illness in children worldwide. Immunoglobulin or glucocorticoids, or both, are currently recommended treatments. Methods: The Best Available Treatment Study evaluated immunomodulatory treatments for MIS-C in an international observational cohort. Analysis of the first 614 patients was previously reported. In this propensity-weighted cohort study, clinical and outcome data from children with suspected or proven MIS-C were collected onto a web-based Research Electronic Data Capture database. After excluding neonates and incomplete or duplicate records, inverse probability weighting was used to compare primary treatments with intravenous immunoglobulin, intravenous immunoglobulin plus glucocorticoids, or glucocorticoids alone, using intravenous immunoglobulin as the reference treatment. Primary outcomes were a composite of inotropic or ventilator support from the second day after treatment initiation, or death, and time to improvement on an ordinal clinical severity scale. Secondary outcomes included treatment escalation, clinical deterioration, fever, and coronary artery aneurysm occurrence and resolution. This study is registered with the ISRCTN registry, ISRCTN69546370. Findings: We enrolled 2101 children (aged 0 months to 19 years) with clinically diagnosed MIS-C from 39 countries between June 14, 2020, and April 25, 2022, and, following exclusions, 2009 patients were included for analysis (median age 8·0 years [IQR 4·2–11·4], 1191 [59·3%] male and 818 [40·7%] female, and 825 [41·1%] White). 680 (33·8%) patients received primary treatment with intravenous immunoglobulin, 698 (34·7%) with intravenous immunoglobulin plus glucocorticoids, 487 (24·2%) with glucocorticoids alone; 59 (2·9%) patients received other combinations, including biologicals, and 85 (4·2%) patients received no immunomodulators. There were no significant differences between treatments for primary outcomes for the 1586 patients with complete baseline and outcome data that were considered for primary analysis. Adjusted odds ratios for ventilation, inotropic support, or death were 1·09 (95% CI 0·75–1·58; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids and 0·93 (0·58–1·47; corrected p value=1·00) for glucocorticoids alone, versus intravenous immunoglobulin alone. Adjusted average hazard ratios for time to improvement were 1·04 (95% CI 0·91–1·20; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids, and 0·84 (0·70–1·00; corrected p value=0·22) for glucocorticoids alone, versus intravenous immunoglobulin alone. Treatment escalation was less frequent for intravenous immunoglobulin plus glucocorticoids (OR 0·15 [95% CI 0·11–0·20]; p<0·0001) and glucocorticoids alone (0·68 [0·50–0·93]; p=0·014) versus intravenous immunoglobulin alone. Persistent fever (from day 2 onward) was less common with intravenous immunoglobulin plus glucocorticoids compared with either intravenous immunoglobulin alone (OR 0·50 [95% CI 0·38–0·67]; p<0·0001) or glucocorticoids alone (0·63 [0·45–0·88]; p=0·0058). Coronary artery aneurysm occurrence and resolution did not differ significantly between treatment groups. Interpretation: Recovery rates, including occurrence and resolution of coronary artery aneurysms, were similar for primary treatment with intravenous immunoglobulin when compared to glucocorticoids or intravenous immunoglobulin plus glucocorticoids. Initial treatment with glucocorticoids appears to be a safe alternative to immunoglobulin or combined therapy, and might be advantageous in view of the cost and limited availability of intravenous immunoglobulin in many countries. Funding: Imperial College London, the European Union's Horizon 2020, Wellcome Trust, the Medical Research Foundation, UK National Institute for Health and Care Research, and National Institutes of Health

Immunoglobulin, glucocorticoid, or combination therapy for multisystem inflammatory syndrome in children: a propensity-weighted cohort study

Background Multisystem inflammatory syndrome in children (MIS-C), a hyperinflammatory condition associated with SARS-CoV-2 infection, has emerged as a serious illness in children worldwide. Immunoglobulin or glucocorticoids, or both, are currently recommended treatments. Methods The Best Available Treatment Study evaluated immunomodulatory treatments for MIS-C in an international observational cohort. Analysis of the first 614 patients was previously reported. In this propensity-weighted cohort study, clinical and outcome data from children with suspected or proven MIS-C were collected onto a web-based Research Electronic Data Capture database. After excluding neonates and incomplete or duplicate records, inverse probability weighting was used to compare primary treatments with intravenous immunoglobulin, intravenous immunoglobulin plus glucocorticoids, or glucocorticoids alone, using intravenous immunoglobulin as the reference treatment. Primary outcomes were a composite of inotropic or ventilator support from the second day after treatment initiation, or death, and time to improvement on an ordinal clinical severity scale. Secondary outcomes included treatment escalation, clinical deterioration, fever, and coronary artery aneurysm occurrence and resolution. This study is registered with the ISRCTN registry, ISRCTN69546370. Findings We enrolled 2101 children (aged 0 months to 19 years) with clinically diagnosed MIS-C from 39 countries between June 14, 2020, and April 25, 2022, and, following exclusions, 2009 patients were included for analysis (median age 8·0 years [IQR 4·2–11·4], 1191 [59·3%] male and 818 [40·7%] female, and 825 [41·1%] White). 680 (33·8%) patients received primary treatment with intravenous immunoglobulin, 698 (34·7%) with intravenous immunoglobulin plus glucocorticoids, 487 (24·2%) with glucocorticoids alone; 59 (2·9%) patients received other combinations, including biologicals, and 85 (4·2%) patients received no immunomodulators. There were no significant differences between treatments for primary outcomes for the 1586 patients with complete baseline and outcome data that were considered for primary analysis. Adjusted odds ratios for ventilation, inotropic support, or death were 1·09 (95% CI 0·75–1·58; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids and 0·93 (0·58–1·47; corrected p value=1·00) for glucocorticoids alone, versus intravenous immunoglobulin alone. Adjusted average hazard ratios for time to improvement were 1·04 (95% CI 0·91–1·20; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids, and 0·84 (0·70–1·00; corrected p value=0·22) for glucocorticoids alone, versus intravenous immunoglobulin alone. Treatment escalation was less frequent for intravenous immunoglobulin plus glucocorticoids (OR 0·15 [95% CI 0·11–0·20]; p<0·0001) and glucocorticoids alone (0·68 [0·50–0·93]; p=0·014) versus intravenous immunoglobulin alone. Persistent fever (from day 2 onward) was less common with intravenous immunoglobulin plus glucocorticoids compared with either intravenous immunoglobulin alone (OR 0·50 [95% CI 0·38–0·67]; p<0·0001) or glucocorticoids alone (0·63 [0·45–0·88]; p=0·0058). Coronary artery aneurysm occurrence and resolution did not differ significantly between treatment groups. Interpretation Recovery rates, including occurrence and resolution of coronary artery aneurysms, were similar for primary treatment with intravenous immunoglobulin when compared to glucocorticoids or intravenous immunoglobulin plus glucocorticoids. Initial treatment with glucocorticoids appears to be a safe alternative to immunoglobulin or combined therapy, and might be advantageous in view of the cost and limited availability of intravenous immunoglobulin in many countries. Funding Imperial College London, the European Union's Horizon 2020, Wellcome Trust, the Medical Research Foundation, UK National Institute for Health and Care Research, and National Institutes of Health

THE RISK FACTORS AND EVALUATION CRITERIA FOR PROGRESSION OF ATHEROSCLEROSIS IN ONE YEAR POST CORONARY BYPASS

Aim. To assess risk factors and to compare evaluation criteria of non-coronary atherosclerosis progression in coronary heart disease patients in 1 year post coronary bypass surgery (CBG).Material and methods. Of 732 consequtive patients (586 males, 146 females, median age 59 y.o.) underwent CBG, 504 were investigated second time in 1 year after operation. Patients underwent ultrasound study (US) of carotid and peripheral arteries with measurement of intima-media thickness. Ankle-brachial index (ABI) was measured automatically with sphygmomanometer VaSeraVS-1000 (Fukuda Denshi,Japan). In blood, lipids were tested. Based on the stenosis indexes NASCET and ECST, the groups were selected: &lt;30% (minor stenosis); 30-49% (moderate stenosis); 50-69% (severe stenosis); 70-99% (critical stenosis); occlusion; absence of stenoses. Criteria for progression of atherosclerosis was existence of at least one sign: transition of non-coronary stenosis from one group to another by US; decrease of ABI during 1 year below0,9 in normal baseline;  decrease of ABI &gt;10% if the baseline ABI lower than 0,9. For analysis, two groups were selected: group 1 (n=375) without progression, and group 2 (n=129) with progression of atherosclerosis. The relation of possible factors to probaility of  on-coronary atherosclerosis progression was evaluated in logistic regression model.Results. Levels of the total cholesterol (TC) and low density lipoproteides cholesterol (LDL-C) were higher in patients with progression of atherosclerosis. In dynamics, significantly in both groups the level of high density lipoproteides cholestrol (HDL-C) increased (p&lt;0,001), and triglycerides decreased (p&lt;0,05). In intergroup analysis, ABI values were higher in the group with no progression of atherosclerosis (p&lt;0,001). In dynamics, in the group of atherosclerosis progression there was significant ABI decrease (p&lt;0,05). In non-progression group ABI, remaning in reference range, significantly decreased during a year after CBG (p&lt;0,05). Thickness of CIM in the non-progression group significantly decreased during a year post-surgery, but in progression group the difference was non-significant. In monofactorial logistic regression, probability of atherosclerosis progression increased with the increase of age, in smoking anamnesis before surgery, in increase of TC and LDL-C, as with GFR decline and in baseline multifocal atherosclerosis presence. Multifactorial analysis showed remaining statistical significance for the several arterial regions, and adverse lipid profile.Conclusion. In one year post-CBG, progression of non-coronary atheroslerosis is marked in 25,6% of patients. In one year post-CBG, ABI decreases independently from the presence of non-coronary atherosclerosis. Factors associated with atherosclerosis progression, were multifocality, level of TC and LDL-C

On the Development and Application of Multiple Cases for Accreditation of Health Care Professionals

The sequence for the development of the multiple case methodology (training technology) for accreditation of health care professionals has been presented. The multidimensionality of cases allows to cover all functions of professional standards. To improve the technique reliability, the multiple-choice tests have been offered. The requirement of local independence of tasks has been implemented. The results of approbation of cases with participation of 114 graduates (6th year) of 5 medical universities have been analysed. The interpretation of the analysis results and their use for assessing the professional readiness of health care professionals have been offered

Treatment of Multisystem Inflammatory Syndrome in Children

BACKGROUND Evidence is urgently needed to support treatment decisions for children with multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2. METHODS We performed an international observational cohort study of clinical and outcome data regarding suspected MIS-C that had been uploaded by physicians onto a Web-based database. We used inverse-probability weighting and generalized linear models to evaluate intravenous immune globulin (IVIG) as a reference, as compared with IVIG plus glucocorticoids and glucocorticoids alone. There were two primary outcomes: the first was a composite of inotropic support or mechanical ventilation by day 2 or later or death; the second was a reduction in disease severity on an ordinal scale by day 2. Secondary outcomes included treatment escalation and the time until a reduction in organ failure and inflammation. RESULTS Data were available regarding the course of treatment for 614 children from 32 countries from June 2020 through February 2021; 490 met the World Health Organization criteria for MIS-C. Of the 614 children with suspected MIS-C, 246 received primary treatment with IVIG alone, 208 with IVIG plus glucocorticoids, and 99 with glucocorticoids alone; 22 children received other treatment combinations, including biologic agents, and 39 received no immunomodulatory therapy. Receipt of inotropic or ventilatory support or death occurred in 56 patients who received IVIG plus glucocorticoids (adjusted odds ratio for the comparison with IVIG alone, 0.77; 95% confidence interval [CI], 0.33 to 1.82) and in 17 patients who received glucocorticoids alone (adjusted odds ratio, 0.54; 95% CI, 0.22 to 1.33). The adjusted odds ratios for a reduction in disease severity were similar in the two groups, as compared with IVIG alone (0.90 for IVIG plus glucocorticoids and 0.93 for glucocorticoids alone). The time until a reduction in disease severity was similar in the three groups. CONCLUSIONS We found no evidence that recovery from MIS-C differed after primary treatment with IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone, although significant differences may emerge as more data accrue