Consilium Medicum

Background. Coronary chronic total occlusion (CTO) is frequently detected in patients with coronary artery disease (CAD); however, the very long-term outcomes of endovascular treatment for this condition remain insufficiently studied and controversial.

Aim. To evaluate the very long-term clinical and structural-functional outcomes of successful mechanical recanalization and stenting of CTO in patients with CAD.

Materials and methods. This multicenter retrospective study included 50 patients with CAD who underwent successful mechanical recanalization of CTO between 2005 and 2018. CTO was defined as complete absence of antegrade blood flow in a native coronary artery (Thrombolysis in Myocardial Infarction [TIMI] flow grade 0) for ≥3 months. Preprocedural assessment included noninvasive diagnostic methods for CAD, echocardiography, electrocardiography, and 24-hour ambulatory electrocardiographic monitoring. Invasive assessment was performed using bilateral coronary angiography. Lesion morphology was evaluated using the SYNTAX score, J-CTO score, and the Werner and Rentrop classifications. During the very long-term follow-up, the primary endpoints included major adverse cardiovascular events (MACE) – all-cause mortality, acute myocardial infarction (AMI), and stroke. Secondary endpoints included the individual components of MACE – all-cause mortality, acute myocardial infarction, and stroke, target lesion thrombosis, target vessel restenosis, repeat hospitalizations due to cardiovascular diseases, clinical status according to the Canadian Cardiovascular Society (CCS) angina classification and the New York Heart Association (NYHA) functional classification, as well as structural and functional myocardial parameters, including left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume, and left ventricular end-systolic volume.

Results. The median follow-up duration was 71.3 months (Q1–Q3 38.7–119.7 months, minimum – 12 months, maximum – 240 months). The overall incidence of major adverse cardiovascular events was 24%: all-cause mortality – 10%, acute myocardial infarction – 8%, stroke – 6%. Repeat hospitalizations occurred in 58% of patients. Target lesion thrombosis developed in 4% of cases, while target vessel restenosis was detected in 40% of patients. No significant improvement in LVEF was observed in the overall study population (p=0.431). In the subgroup of patients with restenosis, a small but statistically significant decrease in left ventricular ejection fraction was observed (p=0.038), whereas no significant changes were found in patients without restenosis (p=0.717).

Conclusion. During very long-term follow-up, mechanical recanalization and stenting of CTO in patients with CAD were not associated with marked improvement in clinical status and did not exert a significant favorable effect on myocardial structural and functional parameters.

A low-protein diet has traditionally been used to mitigate the progression of uremic symptoms and to decrease the production of nitrogen-catabolism products in patients with chronic kidney disease (CKD). CKD is prevalent among individuals over 65, and its progression leads to a decline in nutritional status, particularly in protein-energy deficiency, muscle weakness, and functional limitations. These issues are further exacerbated by aging. Malnutrition is regarded as a significant factor in the multifactorial causes of sarcopenia and senile asthenia. Eating disorders in elderly and senile patients are associated with an increased incidence of infections, prolonged and more frequent hospitalizations, extended recovery times, elevated fracture risks, dependency on external assistance, a decline in quality of life, and a higher mortality rate. This situation necessitates the implementation of appropriate medical rehabilitation strategies that consider the complexities of comorbidity and nutritional disorders in these patients. The mechanisms that drive the development of CKD and various geriatric syndromes, such as malnutrition, sarcopenia, and falls, are intricate. They include metabolic acidosis, oxidative stress, overproduction of pro-inflammatory cytokines, secondary hyperparathyroidism, decreased vitamin D levels, and chronic anemia, all of which contribute to reduced physical activity and diminished food intake. Given such complex mechanisms, nutritional support and non-nutritional therapeutic interventions in CKD patients should encompass a range of strategies, including dietary restrictions and dietary supplements. When managing older adults with CKD, physicians face a challenging decision in dietary planning: recommendations to maintain protein intake at 1.2–1.5 g/kg/day to avert malnutrition and sarcopenia must be carefully weighed against nephrologists' advice to limit protein intake to slow CKD progression. This article outlines recommendations for nutritional support in elderly patients with renal impairment and includes a clinical case demonstrating nutritional rehabilitation within a geriatric department.

Pityriasis lichenoides chronica (PLC) is a chronic inflammatory dermatosis of unknown etiology, primarily affecting individuals in their youth and middle age. The clinical polymorphism associated with the rash often complicates the differential diagnosis with other papulosquamous diseases, resulting in diagnostic errors. This case study underscores the importance of a comprehensive clinical and instrumental approach to accurately verify this condition, using our clinical observation as a basis. A 28-year-old male presented to a dermatologist with a generalized itchy rash. At the prehospital stage, the patient was misdiagnosed with allergic dermatitis, guttate psoriasis, and lichen planus due to the similar symptoms, and previous treatments proved ineffective. Upon detailed examination, a symmetrical rash characterized by multiple papules, with wafer-like scales and hemorrhagic elements, was identified on the lower extremities. Dermatoscopy played a crucial role in rectifying the diagnosis, revealing monomorphic punctate vessels and peripheral hypopigmentation. Additionally, a histological examination of a skin biopsy confirmed the diagnosis of PLC by demonstrating parakeratosis, focal spongiosis, keratinocyte apoptosis, basal layer vacuolation, and erythrocyte extravasation. A combination therapy was initiated to address persistent symptoms, including narrow-band ultraviolet B (311 nm) phototherapy, systemic methotrexate at 15 mg per week, and the topical glucocorticosteroid clobetasol. Treatment was well tolerated, with no significant adverse effects. This approach resulted in substantial clinical improvement, complete regression of the rash, and sustained remission over a 4-month follow-up. Therefore, it is imperative to include PLC into the differential diagnostic algorithm for any chronic papulosquamous dermatoses. Early implementation of skin biopsy and dermatoscopy provides reliable diagnostic direction, and the combination of phototherapy and systemic immunosuppression with methotrexate represents a highly effective strategy for managing resistant forms of the disease. This approach minimizes the risk of chronicity and significantly improves patients' quality of life.

Pemphigus refers to a group of rare autoimmune disorders affecting the skin and mucous membranes, which are characterized by the formation of intraepidermal blisters resulting from acantholysis, which is the disruption of intercellular connections between keratinocytes, primarily mediated by desmosome dysfunction. These structures are essential for maintaining cellular adhesion; thus, their impairment leads to blistering and erosive lesions. Histopathological examination typically reveals blisters resulting from desmosome destruction, acanthotic cells, and an accompanying inflammatory response. A notable aspect of pemphigus is the presence of immunoglobulin G (IgG) antibodies to desmoglein, a crucial component of desmosomes that facilitates intercellular adhesion. Clinically, the primary manifestations present as flaccid blisters, which may arise on various regions of the body or mucous membranes, with a particular prevalence in the oral cavity. The etiology of pemphigus vulgaris remains inadequately understood, though it is posited that a combination of genetic predispositions and environmental factors contributes to disease onset. Diagnosing pemphigus vulgaris can be particularly challenging when only oral mucosal lesions are evident, as such presentations may resemble other conditions such as stomatitis, herpes, or other infections. In such instances, diagnosis is confirmed by identifying IgG antibodies to desmoglein by immunofluorescence assay, along with histological and immunohistochemical analysis of affected tissues. These diagnostic procedures facilitate the accurate differentiation of pemphigus from other bullous diseases. This article presents a clinical case of pemphigus vulgaris in a young female patient who exhibited multiple grouped blisters, vesicles, and bullae on an erythematous base, with dense caps and signs of collapsed elements. A comprehensive examination, including pathomorphological and immunohistochemical assessments of the skin, confirmed the diagnosis. The diagnostic work-up was complicated by atypical clinical manifestations and the need to distinguish the condition from infectious diseases, notably chickenpox and Dühring's dermatitis herpetiformis, prompting consultation with an infectious disease specialist to exclude viral infections. This case underscores the importance of a thorough, timely diagnostic evaluation for rare or atypical manifestations of pemphigus to prevent misdiagnosis and inappropriate treatment. Effective management includes immunosuppressive medications and topical agents, as well as antibiotic therapy when a bacterial infection is present. Early diagnosis and appropriate treatment are vital for significantly improving the patient's condition, enhancing quality of life, and mitigating the risk of complications such as secondary infections and disease progression.

Background. Vibroacoustic lung therapy (VALT) is a hardware method of exposure used in conditions accompanied by hyperproduction of bronchial mucus and impaired evacuation from the respiratory tract. Damage to the alveolar epithelium, as well as a high risk of extensive atelectasis in pneumonia caused by COVID-19, can lead to impaired gas exchange. The proven effectiveness of VALT in a wide range of bronchopulmonary diseases allows us to consider this method as potentially promising in the treatment of COVID-19 associated pneumonia.

Aim. Evaluation of the effectiveness of VALT using the BARK VibroLUNG device (manufactured by BARK Technology, Kazakhstan) in patients with COVID-19 associated pneumonia.

Materials and methods. The study included 70 patients treated for COVID-19 associated pneumonia, who were divided into 2 equal groups: the main group, which used VALT along with standard therapy, and the control group, which received only conventional treatment. The analysis included clinical parameters, arterial blood PaO₂, data from a general blood test, a biochemical blood test, the degree of damage to lung tissue according to computer tomography of the chest organs at the beginning of the study and after its completion, as well as the duration of hospital stay.

Results. The analysis of respiratory rate (RR) dynamics showed a statistically significant decrease in the VALT group. PaO₂, SpO₂ in the air, and SpO₂ on the background of oxygen support did not show significant dynamics. After stratification of patients by disease outcome, positive dynamics of ∆RR, ∆PaO₂, ∆SpO₂ in the air, ∆SpO₂ on the background of oxygen support in the subgroup of surviving patients and a significant deterioration in parameters among the deceased were revealed. When assessing the prognostic significance of the dynamics of clinical and functional indicators against the background of the use of VALT in relation to patient survival, ∆PaO₂, ∆VAS, ∆SpO₂ had good prognostic value, as well as SpO₂ on O₂ had a slightly lower but statistically significant prognostic value.

Conclusion. The inclusion of VALT in the complex treatment of patients with COVID-19-associated pneumonia was accompanied by a decrease in the severity of respiratory failure. A favorable outcome of the disease was associated with a marked decrease in RR and an improvement in oxygenation parameters, while a deterioration in these indicators characterized patients with an unfavorable prognosis. An improvement in gas exchange parameters and a decrease in the severity of dyspnea on the background of VALT can be considered as an early marker of the effectiveness of therapy.

Background. The Voronezh region is classified as an area with a natural iodine deficiency. The lack of a federal law mandating universal iodization of salt in Russia necessitates regular monitoring of iodine availability, particularly among vulnerable groups of the child population. Recent studies indicate a combined impact of iodine deficiency and anthropogenic factors on the development of thyroid pathology.

Aim. To assess the current iodine availability and the prevalence of thyroid pathology among children aged 7–10 years in various districts of the Voronezh region.

Materials and methods. In September-October 2024, a cross-sectional (cluster) study was conducted involving 1,000 children across five districts of the region (Voronezh City, Novovoronezh City, Bobrovsky, Buturlinovsky, and Olkhovatsky districts). The program included: a questionnaire survey, anthropometry, palpation, and ultrasound examination of the thyroid gland (Thyroid Ultrasound) with volume calculation using the ellipsoid formula (M. Zimmermann, 2004), determination of iodine concentration in spot urine samples using the cerium-arsenite method in the laboratory of the Endocrinology Research Centre, as well as a qualitative rapid analysis of food salt samples from households (n=1000) for the presence of potassium iodate.

Results. The median iodine concentration in urine (µg/L) for the region was 98.65 µg/L [Q1–Q3: 62.4; 142.8], indicating a mild degree of iodine deficiency (<100 µg/L). The proportion of samples with iodine levels <50 µg/L was 6.2%. The average prevalence of diffuse goiter based on ultrasound data was 7.3% (ranging from 0.8% to 10.6%), exceeding sporadic levels (<5%). Structural changes in the thyroid gland were identified in 15.4% of children, predominantly focal. The proportion of households using iodized salt was critically low at 16.5% (ranging from 4% to 23.2% in different districts).

Conclusion. In the examined children, the median urinary iodine concentration corresponded to mild iodine deficiency at the population level; diffuse goiter prevalence was 7.3%, and the proportion of households using iodized salt was 16.5%. The findings indicate the need to strengthen regional monitoring of iodine status and preventive measures.

Background. Individual variability in therapeutic response at the early stages of carbohydrate metabolism disorders is largely determined by genetic factors. One of the key genes involved in the regulation of energy homeostasis is ADRB2, which encodes the β₂-adrenergic receptor. The rs1042714 polymorphism may influence tissue sensitivity to insulin and the effectiveness of therapeutic interventions. However, evidence regarding its role in the dynamics of metabolic parameters in individuals with early disturbances of carbohydrate metabolism remains limited.

Aim. To investigate the effect of the ADRB2 rs1042714 polymorphism on carbohydrate metabolism indicators and their changes under different therapeutic strategies in patients with early carbohydrate metabolism disorders.

Materials and methods. The study included 104 participants with risk factors for type 2 diabetes mellitus, residing in the Republic of Tatarstan. Inclusion criteria comprised a history of a single episode of elevated fasting plasma glucose and one or more risk factors for type 2 diabetes mellitus. All participants underwent ADRB2 rs1042714 genotyping. Fasting glucose, glycated hemoglobin (HbA_1c), insulin, C-peptide, lipid profile, as well as HOMA-IR, HOMA-β, and their modified C-peptide – adjusted versions were assessed. Patients were randomized into two therapeutic groups – diet therapy and diet therapy plus metformin – and followed for three months.

Results. Carriers of the CC, CG, and GG genotypes did not differ in age, sex, or baseline metabolic parameters (p>0,05). After three months, CC carriers showed a significant decrease in fasting glucose, C-peptide, and HOMA-IR(CP) values, accompanied by an increase in HOMA-β (p<0,05), indicating improved insulin sensitivity. In contrast, carriers of the minor G allele demonstrated an opposite trend – higher HOMA-IR and fasting glucose. No significant differences were observed between the diet-only and diet-plus-metformin groups (p>0,05).

Conclusion. The rs1042714 polymorphism of the ADRB2 gene contributes to the metabolic response characteristics in patients with early carbohydrate metabolism disorders. The CC genotype is linked to a more advantageous metabolic pattern and enhanced insulin sensitivity in peripheral tissues, while the presence of the G allele appears to contribute to the progression of insulin resistance.

Background. The presence of diabetes mellitus (DM) is a significant predictor of severe COVID-19. Of particular scientific and clinical interest is a cohort of patients with carbohydrate metabolism disorders first identified during hospitalization for the coronavirus disease 2019, which continues to generate interest.

Aim. To analyze the clinical and laboratory characteristics of patients with newly diagnosed diabetes during hospitalization for COVID-19 in comparison with patients without previously diagnosed type 2 DM and to evaluate the prognosis for the outcome of the disease.

Materials and methods. A retrospective analysis of 645 medical records of patients with confirmed SARS-CoV-2 infection hospitalized at two reference centers in 2020–2021 was conducted. Three study groups were formed: a group without DM (n=330); a group with previously diagnosed type 2 DM (n=252); a group with newly diagnosed diabetes during hospitalization for COVID-19 (n=63). More than 120 parameters were analyzed, including demographic, clinical, laboratory, and instrumental ones. Statistical analysis was performed using Stattech (v.4.0) and IBM SPSS Statistics (v.27.0) software.

Results. The overall mortality rate among patients was 31.3% (202/645). Mortality in the group with newly diagnosed diabetes was 38.1% of cases and did not differ significantly from other groups (p=0.447). However, dynamics by year of hospitalization were revealed: mortality in 2020 was 62.5%, decreasing to 12.9% in 2021 (p<0.001). For this group, mortality was not affected by gender (p=0.325), blood glucose level on admission (p=0.058), and lung lesion volume according to computed tomography (CT) data (p=0.361). The key prognostic factors for an unfavorable outcome were earlier hospitalization due to the severity of the infectious process (6th day from the onset of symptoms in deceased vs 8th day in survivors; p=0.011) and indicators of respiratory failure.

Conclusion. Patients with newly diagnosed diabetes due to COVID-19 represent a heterogeneous group with unique prognostic characteristics that differ from those of patients with previously diagnosed type 2 DM. Management of this group requires a specialized protocol with an emphasis on early respiratory monitoring and mandatory follow-up endocrinological monitoring to verify the type of DM.