СТАЦИОНАРНОЕ ОТДЕЛЕНИЕ СКОРОЙ МЕДИЦИНСКОЙ ПОМОЩИ И ЕГО РОЛЬ В ОПТИМИЗАЦИИ РАБОТЫ ОТДЕЛЕНИЙ РЕАНИМАЦИИ МНОГОПРОФИЛЬНОГО СТАЦИОНАРА

In-patient emergency department is a new division, being organized in medical units providing emergency care. In this country, its role and place within medical care system are not fully definite. Goal: to compare work of intensive care departments in hospitals providing care for emergency patients depending if an in-patient emergency department with the intensive care ward is available or absent. Materials. Summarized data on the patients admitted for emergency care to Dzhanilidze St. Petersburg Research Institute of Emergency Care (2010–2012) and Pavlov First Saint Petersburg State Medical University (2014–2016) where the in-patient emergency department is available. Results. Establishment of the in-patient emergency department with the intensive care ward results in the 2-fold reduction of patients' admission to the hospital intensive care department thus reducing the admission of patients with diseases beyond the hospital's specialization. Thus the excessive workload of the intensive care department personnel is reduced and care options are expanded since the duration of the patients' stay is increased while the number of beds remains the same. Conclusion: Adding the in-patient emergency department to the structure of a multi-specialty hospital allows changing the system of medical care, concentrating the efforts and funds on the treatment of patients with absolute indications for admission to the intensive care wards. Стационарное отделение скорой медицинской помощи (СтОСМП) – новое структурное подразделение, создаваемое в медицинских организациях, оказывающих экстренную помощь. Его роль и место в нашей стране в системе лечебных мероприятий в полной мере не ясны. Цель: сравнить работу отделений реанимации и интенсивной терапии (ОРИТ) стационаров, осуществляющих прием пациентов экстренного профиля, в зависимости от наличия или отсутствия в структуре учреждения СтОСМП с палатой реанимации и интенсивной терапии. Материал. Обобщены данные о пациентах, поступивших в экстренном порядке в Санкт-Петербургский НИИ скорой помощи им. И. И. Джанелидзе (2010–2012 гг.) и в ПСПбГМУ им. И. П. Павлова (2014–2016 гг.), в котором функционирует стационарное отделение скорой медицинской помощи. Результаты. Создание СтОСМП с палатой реанимации и интенсивной терапии позволяет в 2 раза сократить госпитализацию пациентов в ОРИТ стационара, уменьшая поступление в них непрофильных пациентов. Соответственно, это снимает избыточную нагрузку на персонал ОРИТ, расширяет возможности ОРИТ с увеличением продолжительности пребывания в них пациентов без увеличения коечной емкости. Вывод. Включение в структуру многопрофильного стационара стационарного отделения скорой медицинской помощи позволяет перестроить систему оказания медицинской помощи, сосредоточить силы и средства на лечении больных и пострадавших, имеющих абсолютные показания для госпитализации в ОРИТ.

Rheumatology training experience across Europe : Analysis of core competences

Publisher Copyright: © 2016 The Author(s). Copyright: Copyright 2019 Elsevier B.V., All rights reserved.Background: The aim of this project was to analyze and compare the educational experience in rheumatology specialty training programs across European countries, with a focus on self-reported ability. Method: An electronic survey was designed to assess the training experience in terms of self-reported ability, existence of formal education, number of patients managed and assessments performed during rheumatology training in 21 core competences including managing specific diseases, generic competences and procedures. The target population consisted of rheumatology trainees and recently certified rheumatologists across Europe. The relationship between the country of training and the self-reported ability or training methods for each competence was analyzed through linear or logistic regression, as appropriate. Results: In total 1079 questionnaires from 41 countries were gathered. Self-reported ability was high for most competences, range 7.5-9.4 (0-10 scale) for clinical competences, 5.8-9.0 for technical procedures and 7.8-8.9 for generic competences. Competences with lower self-reported ability included managing patients with vasculitis, identifying crystals and performing an ultrasound. Between 53 and 91 % of the trainees received formal education and between 7 and 61 % of the trainees reported limited practical experience (managing ≤10 patients) in each competence. Evaluation of each competence was reported by 29-60 % of the respondents. In adjusted multivariable analysis, the country of training was associated with significant differences in self-reported ability for all individual competences. Conclusion: Even though self-reported ability is generally high, there are significant differences amongst European countries, including differences in the learning structure and assessment of competences. This suggests that educational outcomes may also differ. Efforts to promote European harmonization in rheumatology training should be encouraged and supported.publishersversionPeer reviewe

Effects of alirocumab on types of myocardial infarction: insights from the ODYSSEY OUTCOMES trial

Aims  The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into five types: Type 1, spontaneous; Type 2, related to oxygen supply/demand imbalance; Type 3, fatal without ascertainment of cardiac biomarkers; Type 4, related to percutaneous coronary intervention; and Type 5, related to coronary artery bypass surgery. Low-density lipoprotein cholesterol (LDL-C) reduction with statins and proprotein convertase subtilisin–kexin Type 9 (PCSK9) inhibitors reduces risk of MI, but less is known about effects on types of MI. ODYSSEY OUTCOMES compared the PCSK9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome (ACS) and elevated LDL-C (≥1.8 mmol/L) despite intensive statin therapy. In a pre-specified analysis, we assessed the effects of alirocumab on types of MI. Methods and results  Median follow-up was 2.8 years. Myocardial infarction types were prospectively adjudicated and classified. Of 1860 total MIs, 1223 (65.8%) were adjudicated as Type 1, 386 (20.8%) as Type 2, and 244 (13.1%) as Type 4. Few events were Type 3 (n = 2) or Type 5 (n = 5). Alirocumab reduced first MIs [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77–0.95; P = 0.003], with reductions in both Type 1 (HR 0.87, 95% CI 0.77–0.99; P = 0.032) and Type 2 (0.77, 0.61–0.97; P = 0.025), but not Type 4 MI. Conclusion  After ACS, alirocumab added to intensive statin therapy favourably impacted on Type 1 and 2 MIs. The data indicate for the first time that a lipid-lowering therapy can attenuate the risk of Type 2 MI. Low-density lipoprotein cholesterol reduction below levels achievable with statins is an effective preventive strategy for both MI types.For complete list of authors see http://dx.doi.org/10.1093/eurheartj/ehz299</p

Разработка верифицированной шкалы риска остеоартрита на основе кросс-секционного исследования клинико-анамнестических параметров и фармакологического анамнеза пациентов

Objective: the development and verification of a scale for identifying patients at high risk of osteoarthritis (OA).Material and methods. The results of the analysis of a sample of patients aged 35–90 years from the database of the Institute of Trace Elements (n=3440), which included information on clinical and anamnestic, diagnostic parameters and pharmacotherapy of patients, including patients with OA (n=107), are presented. To analyze information about patients, modern methods of data analysis proposed within the topological theory of pattern recognition were used.Results. Based on the analysis of the sample, a 100-point scale of 27 points was developed which allows to identify patients at high risk of OA (sensitivity 88%, specificity 100%). For patients with high scores on the scale, a kind of “preemptive” prescription of symptomatic slowacting drugs for osteoarthritis (SySADOA) based on highly purified substances of chondroitin sulfate (CS) and glucosamine sulfate (GS) is promising. The evidence for CS/GS is extensive and has been reviewed previously.Conclusion. Early adoption of preventive measures (including the usage of SySADOA – CS/GS) in patients with a high score on the developed scale may reduce the risk of OA.Цель: разработка и верификация шкалы для выявления пациентов с высоким риском остеоартрита (ОА).Материал и методы. Представлены результаты анализа выборки пациентов в возрасте 35–90 лет из базы данных Института микроэлементов (n=3440), включившей информацию о клинико-анамнестических, диагностических параметрах и фармакотерапии больных, в т.ч. пациентов с ОА (n=107). Для анализа информации о пациентах использовали современные методы анализа данных, развиваемые в рамках топологической теории распознавания.Результаты. На основании анализа выборки разработана 100-балльная шкала из 27 пунктов, позволяющая выявлять больных с высоким риском ОА (чувствительность 88%, специфичность 100%). Для пациентов с высокими баллами по шкале перспективно своего рода «упреждающее» назначение симптоматических лекарственных средств замедленного действия (СЛСЗД) на основе высокоочищенных субстанций хондроитина сульфата (ХС) и глюкозамина сульфата (ГС). Доказательная база по ХС/ГС весьма обширна и была рассмотрена ранее.Заключение. Заблаговременное принятие профилактических мер (в т.ч. назначение СЛСЗД на основе ХС/ГС) у пациентов с высоким баллом по разработанной шкале может снизить риск ОА

Effect of alirocumab on mortality after acute coronary syndromes. An analysis of the ODYSSEY OUTCOMES randomized clinical trial

Background: Previous trials of PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitors demonstrated reductions in major adverse cardiovascular events, but not death. We assessed the effects of alirocumab on death after index acute coronary syndrome. Methods: ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) was a double-blind, randomized comparison of alirocumab or placebo in 18 924 patients who had an ACS 1 to 12 months previously and elevated atherogenic lipoproteins despite intensive statin therapy. Alirocumab dose was blindly titrated to target achieved low-density lipoprotein cholesterol (LDL-C) between 25 and 50 mg/dL. We examined the effects of treatment on all-cause death and its components, cardiovascular and noncardiovascular death, with log-rank testing. Joint semiparametric models tested associations between nonfatal cardiovascular events and cardiovascular or noncardiovascular death. Results: Median follow-up was 2.8 years. Death occurred in 334 (3.5%) and 392 (4.1%) patients, respectively, in the alirocumab and placebo groups (hazard ratio [HR], 0.85; 95% CI, 0.73 to 0.98; P=0.03, nominal P value). This resulted from nonsignificantly fewer cardiovascular (240 [2.5%] vs 271 [2.9%]; HR, 0.88; 95% CI, 0.74 to 1.05; P=0.15) and noncardiovascular (94 [1.0%] vs 121 [1.3%]; HR, 0.77; 95% CI, 0.59 to 1.01; P=0.06) deaths with alirocumab. In a prespecified analysis of 8242 patients eligible for ≥3 years follow-up, alirocumab reduced death (HR, 0.78; 95% CI, 0.65 to 0.94; P=0.01). Patients with nonfatal cardiovascular events were at increased risk for cardiovascular and noncardiovascular deaths (P<0.0001 for the associations). Alirocumab reduced total nonfatal cardiovascular events (P<0.001) and thereby may have attenuated the number of cardiovascular and noncardiovascular deaths. A post hoc analysis found that, compared to patients with lower LDL-C, patients with baseline LDL-C ≥100 mg/dL (2.59 mmol/L) had a greater absolute risk of death and a larger mortality benefit from alirocumab (HR, 0.71; 95% CI, 0.56 to 0.90; Pinteraction=0.007). In the alirocumab group, all-cause death declined wit h achieved LDL-C at 4 months of treatment, to a level of approximately 30 mg/dL (adjusted P=0.017 for linear trend). Conclusions: Alirocumab added to intensive statin therapy has the potential to reduce death after acute coronary syndrome, particularly if treatment is maintained for ≥3 years, if baseline LDL-C is ≥100 mg/dL, or if achieved LDL-C is low. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01663402

Efficient estimation methods for non‑Gaussian regression models in continuous time

In this paper, we develop an efficient nonparametric estimation theory for continuous time regression models with non-Gaussian Lévy noises in the case when the unknown functions belong to Sobolev ellipses. Using the Pinsker’s approach, we provide a sharp lower bound for the normalized asymptotic mean square accuracy. However, the main result obtained by Pinsker for the Gaussian white noise model is not correct without additional conditions for the ellipse coefficients. We find such constructive sufficient conditions under which we develop efficient estimation methods. We show that the obtained conditions hold for the ellipse coefficients of an exponential form. For exponential coefficients, the sharp lower bound is calculated in explicit form. Finally, we apply this result to signals number detection problems in multi-pass connection channels and we obtain an almost parametric convergence rate that is natural for this case, which significantly improves the rate with respect to power-form coefficients

ACUTE ARTICULAR SYNDROME. THE CONCEPT OF EMERGENCY CARE IN RHEUMATOLOGY

The absence of a current emergency care system for rheumatic patients makes the solution of this problem relevant. Objective: to create and test a health care system for patients with acute articular syndrome (AAS) and to analyze the distribution of patients according to the profile of hospitalization. Subjects and methods. The practice of providing medical care to patients with AAS was studied using the materials of the I.I. Dzhanelidze Research Institute of Emergency Care (RI of EC) in 2008 to 2015. The causes of hospital admissions were analyzed by taking into account the verified nosological diagnosis. Results and discussion. The incidence of AAS in the general flow of patients referred for hospitalization was analyzed; the most frequent causes of AAS were determined. Trends in the referral of rheumatic patients to inpatient and outpatient treatment were analyzed separately. The decrease in the proportion of rheumatic patients in need of inpatient treatment from 76.7 to 50.8% during the study allows optimization of the costs of the health care system. Conclusion. The presented concept of providing medical care to patients with AAS has proven its effectiveness as a result of its testing at the RI of EC from 2008 to the present time. This concept can be recommended for its introduction in other subjects of the Russian Federation

Эффективное непараметрическое оценивание квадратично интегрируемых функций в моделях непрерывной регрессии

In this paper we study an asymptotic efficiency property of the weighted least squares estimates for unknown square inte- grable functions in Gaussian regression models. We use the Pinsker approach. It is established that it is impossible to directl