ISSN (print): 0136-1449, ISSN (online): 2687-1408 Founder: Perm State Medical University named after. ak. E.A. Wagner Editor-in-Chief: Eugene G. Furman, Corresponding Member of the Russian Academy of Sciences, MD, PhD, professor, Frequency / Access: 6 issues per year / Open Included in: Higher Attestation Commission List, RISC
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READ the details online (tap to see in details) Author’s license agreement (public offer) on the publication of an article in a scholarly journal “Perm Medical Journal” Eco-Vector, represented by its CEO Evgeniy Schepin and acting on the basis of the Charter (hereinafter referred to as the Publisher), on the one hand, offers an indefinite circle of persons (hereinafter referred to as the Author), and on the other hand, hereinafter jointly referred to as the Parties, to execute this agreement (hereinafter referred to as the Agreement) on the publication of scientific article (hereinafter referred to as the Article) in a scholarly journal “Perm Medical Journal” (further-the Journal) in accordance with the conditions stated below. I. 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Hepсidin regulation of adaptive immune cell functions
The peptide hormone hepcidin is a key regulator of iron metabolism. Primarily synthesized in the liver, it controls the absorption of iron ions by enterocytes and iron export from cells. Hepcidin acts by binding to its principal target, protein ferroportin, inducing its internalization and degradation, thereby blocking the release of iron ions from cells. Changes in the intracellular level of iron ions are critical for immune cell function. The synthesis of hepcidin, and consequently ferroportin, increases during inflammation in response to proinflammatory cytokines and to infectious agents that stimulate toll-like receptors. Lymphocyte proliferation is a key stage in the development of the adaptive immune response, and iron is essential for this process. The review analyzes current understanding of the mechanisms of hepcidin immunoregulatory activity in relation to the adaptive immunity cells. Regulation of the intracellular levels of iron ions by hepcidin affects the activation and proliferation of T- and B-lymphocytes, directs differentiation of effector subpopulations of T-helper lymphocytes and cytotoxic T-lymphocytes, the formation of memory B-cells and antibody production. The relevance of systematizing knowledge about the mechanisms of regulation of iron metabolism and the immunoregulatory activity of hepcidin is determined by the widespread prevalence of iron deficiency conditions and popularity of iron-containing drugs. Understanding the mechanisms of targeted regulation of iron metabolism has profound fundamental and practical significance and opens up new prospects for the treatment of iron deficiency, infectious, oncological and neurodegenerative diseases.
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The role of iodine deficiency and anthropogenic factors in the epidemiology and pathogenesis of goiter in children
The objective of this review is to identify the pathogenetic features and epidemiological patterns of thyroid goiter development in children exposed to iodine deficiency and anthropogenic pollutants in the regions of the Russian Federation. A systematic analysis of the scientific literature (2015–2024) from the PubMed/MEDLINE, ScienceDirect, eLIBRARY.ru, and CyberLeninka databases was conducted, focusing on original research and clinical guidelines. The coverage time range was 2015–2024. A manual search was also performed in specialized journals, including ("Problemy Endokrinologii" [Problems of Endocrinology], "European Journal of Endocrinology"). Endemic goiter is the leading thyroid pathology among children in the Russian Federation, accounting for 44.5 % of all cases. This is caused by mild to moderate iodine deficiency, which is endemic in approximately 30 regions of the country (Dagestan, Tatarstan, Altai Krai, etc.). The prevalence varies significantly within regions, for example, in Dagestan, it reaches 54.2 % in mountainous areas compared to 19.0 % on the plains, indicating the influence of factors beyond iodine status alone. The incidence peak was observed in adolescents aged 15–17 years (3658.5 per 100,000), with a marked 4:1 female-to-male predominance. In industrial regions such as Chelyabinsk Oblast, one of three thyroid nodules in children shows signs of malignancy. A synergy was identified between iodine deficiency and anthropogenic pollutants (heavy metals, nitrates, uranium and polymetallic ore waste, PM2.5, perchlorates, dietary goitrogens), which block iodine uptake and disrupt hormone synthesis. Thus, thyroid goiter in children is a multifactorial condition. There is a need to develop regionally adapted prevention programs and improve diagnostic algorithms, considering the combined effects of iodine deficiency and anthropogenic pollutants.
Optimization of prenatal care as a measure to reduce reproductive losses and obstetric complications
Objective. To enhance prenatal monitoring of pregnant women by including recommendations for correcting nutrient deficiencies and dosing physical activity. Materials and methods. An individual pregnancy management program based on lifestyle modification and correction of nutrient deficiencies was developed and evaluated. The effectiveness of this program was assessed through a comparative analysis of two groups. Group I included 417 women who followed the program with recommendations for lifestyle modification and correction of nutrient deficiencies. Group II comprised 394 patients who received standard prenatal care according to the conventional protocol at Perm antenatal clinics. The individual pregnancy management program included recommendations for lifestyle modification, physical activity, and fluid intake, as well as a vitamin-mineral complex in combination with individually selected single-nutrient supplements of vitamins and micronutrients. Results. The effectiveness of the proposed program was assessed based on the frequency of obstetric complications and pregnancy outcomes. Intergroup differences were identified in the frequency of miscarriage (χ2 = 4.540; p = 0.034), extremely preterm birth (χ2 = 4.754; p = 0.03), preeclampsia (χ2 = 4.001; p = 0.046), fetal growth restriction (χ2 = 4.501; p = 0.034), intrahepatic cholestasis (χ2 = 6.039; p = 0.014), as well as gestational diabetes mellitus (χ2 = 4.035; p = 0.045). Conclusions. Thus, the obtained data indicate the need to assess individual level of vitamin and nutrient intake, as a basis for a personalized approach to pregnancy management. Consulting pregnant women on nutrition, supplements and physical activity does not contradict current clinical guidelines and falls within the competence of an obstetrician-gynecologist in terms of implementing and monitoring the effectiveness of measures to prevent and promote a healthy lifestyle and select therapeutic nutrition.
The influence of bacteriological monitoring on the choice of treatment strategy in minimally invasive surgical management of patients with intra-abdominal abscesses
Objective. To study the effect of changes in pathogenic microflora as a factor reflecting the effectiveness of treatment of patients with IAA, and its importance in determining the indications for timely correction of minimally invasive inflammatory focus drainage. Materials and methods. Тhe study included 89 patients with IAA treated by percutaneous drainage under ultrasound control at the surgical department of Stavropol Krai State Healthcare Institution City Clinical Hospital of Emergency Medical Care in the period from 2019 to 2024. The contents of the abscesses were collected on the 1st, 3rd, 10th days followed by bacteriological examination of the material for aerobic and facultative anaerobic flora with determination of sensitivity to antibiotics. Results. According to the bacteriological examination of the contents of abscesses taken on the first day, the growth of microorganisms was detected in 75 (84,3 %) patients, with E. coli prevailing (46,1 %). On the third day, the growth of microorganisms was revealed in 77 (86,5 %) patients. At the same time, associations of microorganisms with stable hospital microflora with high antibiotic resistance were found in 18 (20,2 %) of 89 patients. In 31 (34,8 %) cases, including 18 (20,2 %) people with stable hospital microflora and high antibiotic resistance, antibiotic therapy was adjusted. And it was not adjusted in 58 (65,2 %) patients. In 16 (18,0 %) patients out of 89, additional measures to ensure effective drainage of the abscess cavity were required. All of them belonged to the group of 18 (20,2 %) people with stable hospital microflora and high antibiotic resistance. Conclusions. In the majority of patients (65,2 %) with IAA, adjustment of empirical antibiotic therapy was not required, which confirms the primary importance of the effective initial IAA drainage in the treatment, regardless of the size, location, and etiology of the abscess. There is a direct dependence of the microbial landscape of abscesses on the effectiveness of drainage: in case of impaired outflow of contents, insufficient debridement of the abscess, on the third day, the microflora changes to polyresistant hospital strains. Dynamic microbiological monitoring data can serve as an important criterion for the effectiveness of initial drainage, as well as a predictor dictating the need to correct the drains position or additional drainage of the IAA.
Clinical and laboratory features of lymphadenopathy in children
Objective. To analyze examination data of children with lymph node hyperplasia detected on abdominal ultrasound examination. Materials and methods. An analysis of pediatric examination results in the Ultrasound Diagnostics Department of Children's Clinical Hospital No. 13 revealed that 5.8 % of children had enlarged abdominal lymph nodes at the time of examination. All children were hospitalized in the Allergy and Immunology Department. The examination included a complete blood count, comprehensive biochemical blood analysis, and immunological testing. The children were divided into three groups according to the location of the enlarged lymph nodes in the abdominal cavity. Results. The study revealed a weak negative correlation between the De Ritis ratio and total immunoglobulin E levels, with low statistical significance. Conclusions. Thus, in children with acute allergic pathology, abdominal lymph nodes enlargement is not of critical diagnostic importance.
On placental erythropoietin expression in abnormal placentation
Objective. To study placental erythropoietin (EPO) expression in placenta previa and placenta accreta (PAS - placenta accreta spectrum). Materials and methods. A morphological study of placenta was performed in women who delivered at the obstetric department of the Clinic of the South Ural State Medical University (Chelyabinsk, Russia). The sample included 53 placental specimens: group 1 – 21 specimens of normally situated placenta, group 2 – 17 specimens of placenta previa without signs of invasion, group 3 – 15 PAS specimens, comprising 7 cases of placenta accreta, 5 of placenta increta, 3 of placenta percreta (invasion degree 3a). Placental expression was studied using monoclonal antibodies to EPO (EPO antibody Rabbit Polyclonal, suitable for Western blot – WB, immunohistoche­mistry – IHC-P, and ELISA; Human, U.S.A.), the intensity of the immunohistochemical reaction was assessed using a semi-quantitative 3-point scale. Results. Placental EPO expression in abnormal placentation was statistically significantly increased in the capillary endothelial cells of villi (group 1 – 1 (1–2); group 2 – 2 (2–2,5); group 3 – 2 (2–3); p < 0,001) showing an increasing trend in PAS. Specifically, in placental invasion, a marked EPO expression was recorded in syncytiotrophoblast (group 1 – 2 (2–2); group 2 – 2 (2–3); group 3 – 3 (2–3); p1-3 < 0,001; p < 0,001) and villous stroma macrophages (group 1 – 2 (1–2); group 2 – 2 (2–2,5); group 3 – 2 (2–3); p = 0,002), while reduced (moderate) expression was observed in amniotic epithelium (group 1 – 3 (2–3); group 2 – 2 (2–3); group 3 – 2 (2–3); p1-3 = 0,016; p = 0,034). Conclusions. In abnormal placentation, a statistically significant increase was revealed in the number of capillary endothelial cells of placental villi expressing erythropoietin. In PAS, marked erythropoietin expression was observed in syncytiotrophoblast and villous stromal macrophages, with a concurrent decrease in amniotic epithelium. The inclusion of maternal serum erythropoietin concentration measurement in prenatal screening protocols appears promising for assessing the likelihood of placenta previa and placenta accreta.
Cardiovascular disorders in children as a long-term outcome of bronchopulmonary dysplasia
Objective. To assess the frequency and characteristics of cardiovascular disorders (CVD) in 2-year-old children with a history of bronchopulmonary dysplasia (BPD). Materials and methods. A retrospective study was conducted based on the analysis of 137 outpatient records of children discharged from perinatal centers in Yekaterinburg. The study included patients with confirmed BPD. Cardiovascular parameters, physical and psychomotor development, vision, and neurological status were evaluated on the basis of the data recorded in the patients` charts. The children were categorized into CVD risk groups: low (41.7 %), medium (43.9 %), and high (14.2 %). The analysis encompassed echocardiography (EchoCG), electrocardiography (ECG), renal and thymus ultrasound examination results, as well as findings from clinical examination by pediatric cardiologists, ophthalmologists and neurologists. Physical and psychomotor development was assessed using the Griffiths scale and the Denver Development Screening Test II (DDST-II). Methods of statistical analysis. Statistical analysis was performed using Microsoft Excel 2019 and SPSS for Windows, version 20.0. Qualitative data are presented as absolute numbers and percentages; for their comparison, the χ2 test with Yates`s correction and Fisher`s exact test for small sample sizes were applied. The normality of quantitative data distribution was assessed using the Shapiro-Wilk test. For non-normally distributed data, results are presented as median and interquartile range (Me (25 %–75 %)). The Mann – Whitney U test was used to compare quantitative variables between groups. Statistically significant differences were considered with p < 0,05. Results. 2-year-old children in the high-cardiovascular risk group demonstrated a higher frequency of deviations in physical and psychomotor developmental, rhythm disturbances, myocardial repolarization abnormalities, and signs of neurological impairments. These changes were less pronounced in the medium- and low-risk groups. All major differences between groups were statistically significant. The frequency of myopia and astigmatism did not differ between the study groups. The high-risk group also showed a greater prevalence of signs of hypertensive-hydrocephalic syndrome and chronic bronchopulmonary diseases. All major differences between the groups were statistically significant. Conclusions. By the age of 2 years, a high frequency of CVD was identified in children with a history of BPD (66.4 %). The severity of CVD was dependent on the early prognostic risk level: the most severe impairments were observed in the high-risk group, whereas the children in the low- and medium -risk groups had significantly less pronounced changes. The prognostic risk established in the perinatal period influences subsequent outcomes. Thus, the CVD outcomes in 2-year-old children with a history of BPD confirm the critical importance of early risk prognosis for determining the strategy for their further long-term follow-up and individualized management.
Comparative assesment of the third molar hygiene index in patients with and without traumatic mandibular fractures
Objective. To compare the third molar hygiene index (TMHI) in patients with traumatic mandibular fractures and in individuals without this injury. Materials and methods. The study involved 95 individuals aged 18–60 years. They were divided into three groups. Group 1 (n=43): patients with a traumatic mandibular fracture and more than two third molars present. Group 2 (n=21): individuals without a jaw fracture, with more than two third molars present, and with a satisfactory or poor TMHI of these teeth. Group 3 (n=31): individuals without a jaw fracture, with more than two third molars present, and with a good TMHI. The TMHI was determined using the author's method. The data obtained in the study was processed statistically. Results. A comparative assessment of the TMHI among the identified groups revealed statistically significant differences. Comparison of Group 1 with Groups 2 and 3 using the Kruskal-Wallis test showed a significantly lower TMHI values in Group 2 (z1-2=3.78; H=74.87, p=0.0000) and in Group 3 (z1-3=8.63; H=74.87, p=0.0000). Comparison of the TMHI between Groups 2 and 3 also demonstrated significantly lower values in Group 3 (z2-3=3.63; H=74.87, p=0.0000). Conclusions. The obtained results allow us to conclude the following: the TMHI is an informative and well reproducible indicator for assessing the hygiene status of third molars; the status of third molars significantly affects oral homeostasis; the TMHI should be used in conjunction with the O-HIS for a more accurate assessment of a patient's oral hygienic status.
Non-developing pregnancy up to 12 weeks of gestation in women of reproductive age
Objective. To analyze the clinical characteristics of non-developing pregnancy (NDP) cases in the first trimester. Materials and methods. A retrospective study was conducted by reviewing medical records of patients with non-developing pregnancy (NDP) up to 12 weeks of gestation. The analysis focused on associated gynecological and somatic comorbidities, as well as the leading clinical manifestations of this condition. Results. The obtained data demonstrated that the highest incidence of non-developing pregnancy was observed among women living in urban areas, suggesting a possible impact of environmental and epigenetic factors on this gestational pathology development. Contrary to literature data highlighting the key role of maternal age as a risk factor, our analysis found no statistically significant differences between age groups. However, a high prevalence of somatic comorbidities was observed among the examined patients, irrespective of age and residence. Notably, there was a high prevalence of adverse obstetric and gynecological history, including menstrual dysfunction, spontaneous miscarriages, induced abortions, ectopic pregnancies, and recurrent episodes of non-developing pregnancy. Analysis of the timing of pregnancy termination showed that in most cases, the pregnancy loss occurred at up to 5–6 weeks of gestation. The most common clinical symptom was vaginal bleeding, however, in 21 % of cases, NDP was asymptomatic and diagnosed only by ultrasound examination. This underscores the crucial importance of first-trimester ultrasound screening, especially in high-risk groups, such as women with a history of pregnancy loss. Conclusions. Currently, it is generally accepted that for patients with a complicated obstetric history, the absence of preparation and consideration of the pathophysiological features of the reproductive system recovery prior to conception significantly increases the risk of recurrent pregnancy loss.
Improvement of wound treatment in diabetic foot syndrome by a physicochemical method
Objective. To improve the treatment results of patients with diabetic foot syndrome having severe lesions complicated by purulent wounds of the foot and lower leg employing an improved ultrasound wound treatment method. Materials and methods. The study is based on the examination and treatment data of 123 patients with severe diabetic foot syndrome, complicated by purulent wounds of the foot and lower leg, who received inpatient treatment at the Bukhara State Medical Institute Clinic for the period from 2024 to 2025. Results. In the treatment of severe diabetic foot syndrome complicated by purulent wounds of the foot and lower leg, an established approach using combined ultrasound wound treatment with a 25 % dimexide solution and an electroactivated solution – A is more effective than ultrasound treatment of a wound with saline solution or using 25 % dimexide solution. This combined approach demonstrated acceleration of healing processes, reduction of intoxication indicators by an average of 2–4 days, elimination of major amputation cases, significant reduction in amputation rates: shin-level amputation from 18.9 % to 7.5 %, atypical foot resection from 24.3 % to 15.0 %, reamputations from 5.4 % to 0 %, postoperative stump suppuration from 5.4 % to 2.5 % compared to subgroup II A. Conclusions. The use of ultrasound wound treatment with 25 % dimexide solution combined with electroactivated solution A for purulent wounds in diabetic foot syndrome is a more effective method which reduced the average hospital stay from9,6 ± 1,3 до 7,1 ± 0,8 days.
Analysis of the effectiveness of minimally invasive methods for facial skeleton reduction
Objective. To optimize and evaluate the effectiveness of minimally invasive orbital bone reposition while providing qualified medical care to the wounded. Materials and methods. We analyzed the case histories of more than 500 patients with combined and isolated injuries to the zygomatic-nasal-orbital-ethmoidal (ZNOE) complex, admitted to a multidisciplinary hospital over a two-year period. From this cohort, 190 patients were included in the study control group. These patients were divided into groups according to Hooper`s classification (2004). Among them, 94 patients had a fracture with prolapse of soft tissue structures into the maxillary sinus, accompanied by hemosinus, and the presence of foreign bodies of various density and size, 96 patients had type 2 fractures with soft tissue prolapse and hemosinus, but without foreign bodies in the maxillary sinus. Results. No inflammatory complications were recorded in 141 patients in the early postoperative period. In 49 patients, nasal congestion, swelling of the middle third of the face, and limited mouth opening persisted for 2 days after catheter removal. Follow-up visual examination revealed the presence of exudate in the maxillary sinus on the injured side. This finding was associated with exacerbations of chronic odontogenic infection, a factor which requires separate and detailed investigation beyond this study. Conclusions. According to the protocol for the first two stages of evacuation, the primary goals are to eliminate life-threatening conditions and prevent predictable post-traumatic functional impairments. These goals are best achieved using minimally invasive methods. The principles and extent of such gentle surgical techniques are determined by fracture type, the degree of bone fragment displacement, and the risks of predictable functional disorders, particularly those of the visual system. A comparative analysis of the outcomes demonstrates that restoring anatomical integrity – for both isolated and combined injuries – through maximally atraumatic surgical techniques has the best results in terms of functional recovery.
Modern approaches to the comprehensive treatment of chronic venous insufficiency of the lower limbs in the stage of trophic disorders
Objective. Evaluate the clinical effectiveness of minimally invasive treatment methods for chronic venous insufficiency (CVI) of the lower extremities at the stage of trophic disorders (C6 according to the CEAP classification). Materials and methods. A prospective study included 80 patients, divided into two groups: the main group (n = 40) underwent endovenous laser coagulation (EVLC), radiofrequency ablation (RFA), and perforator vein correction, while the control group (n = 40) received conservative therapy. Results. It was shown that in the main group, complete ulcer healing was achieved in 90 % of patients within 12 weeks, whereas in the control group this figure was 55 % (p < 0.01). The recurrence rate during the year was significantly lower with the use of minimally invasive surgery. Thus, minimally invasive treatment methods demonstrate high clinical effectiveness, promote faster ulcer healing and reduce recurrence rates, and may also be considered the preferred therapeutic approach for C6 stage chronic venous insufficiency. Conclusions. The conducted prospective study confirmed the high clinical effectiveness of minimally invasive treatment methods for chronic venous insufficiency of the lower extremities at the stage of trophic disorders (C6 according to the CEAP classification). The use of endovenous laser coagulation and radiofrequency ablation in combination with correction of perforator reflux made it possible to achieve stable healing of trophic ulcers in 90 % of patients within 12 weeks, whereas with conservative therapy alone this indicator was 55 %. Minimally invasive interventions not only accelerate epithelialization of the ulcerative defect, but also significantly reduce recurrence rates, decrease pain, improve venous hemodynamics, and enhance patients’ quality of life. Their safety and suitability for outpatient use make these methods preferable in clinical practice for managing patients with C6-stage chronic venous insufficiency.
Using spatial methods of epidemiological data analysis to improve HIV surveillance
Objective. To develop a geographic information system (GIS) for improvement in epidemiological surveillance for HIV infection in Volga Federal District (VFD), aimed at increasing the effectiveness of monitoring, analyzing spatiotemporal patterns of the infection spread, and optimizing preventive and anti-epidemic measures. Materials and methods. The developed system is a web resource comprising a web application, an administration module, and a database management system. Statistical materials used in the study are: Federal State Statistical Observation forms N61 (“Data on HIV-infected Patient Population”), N4 (“Data on Results of HIV Antibody Blood Tests”), N2 (“Data on Infectious and Parasitic Diseases”); data from the Priority National Project “Prevention of HIV infection, Hepatitis B and C, and Identification and Treatment of HIV Patients”; statistical data from the centers for the prevention and control of AIDS and infectious diseases in the Volga Federal District; classifiers of the administrative-territorial division of the Russian Federation; population statistics for VFD regions. Results. The web application was developed based on the software program "Basic Module "Epidemiological Atlas of Russia" from the existing “Epidemiological Atlas of Russia. Federal District Territory" with key improvements in architectural optimization, unification of data processing logic and performance enhancements achieved through code refactoring. A standardized database model was implemented to systematize the input and resulting epidemiological parameters. Based on user query parameters, the web application dynamically generates an array of epidemiological data with annual temporal resolution and regional spatial detail, visualizing the data through tabular, graphical, and cartographic interfaces. Conclusions. The “Epidemiological Atlas for HIV Infection” represents a comprehensive modernization of the “HIV Infection in VFD” section from the Epidemiological Atlas of Volga Federal District. It is designed to improve and optimize the system of epidemiological surveillance for HIV infection, improve the level of epidemiological assessment of specific features and trends in the epidemic process, provide objective spatial characteristics of HIV incidence in the regions of the district and in Volga Federal District as a whole for timely planning of preventive and anti-epidemic measures. The approach presented for implementation allows for the collection of necessary epidemiological data on HIV infection in any federal district, or the centralized accumulation of data in case of its replication and/or scaling. In the context of healthcare digitalization, this system can become a component of the state strategy for combating HIV infection.
Comprehensive analysis of concomitant and modifying factors in patients with tmj dysfunction: a multicenter study
Objective. To study individual dental and general health parameters in patients with temporomandibular joint dysfunctions to improve the effectiveness of diagnosis and comprehensive treatment of patients with degenerative diseases of the craniomandibular complex. Materials and methods. The research was conducted at 2 clinical sites: the Dental Polyclinic of Ye.A. Vagner Perm State Medical University (Perm, Perm Krai, Russia) and the Department of Maxillofacial Trauma and Orthognathic Surgery of Dental Hospital of Zunyi Medical University (Zunyi, Guizhou Province, China). A health questionnaire was developed for the project, 2 observation groups of young and middle-aged patients (according to the WHO classification) were formed: group A comprised patients from Russia, and group B comprised patients from China. Results. Significant differences were identified in the structure of concomitant somatic conditions among patients with TMJ dysfunction between the Russian Federation and the People`s Republic of China. A number of modifying factors that influence the development and clinical course of the primary dental disorder were determined. The study also demonstrates that implementation of a unified health questionnaire for patients with TMJ dysfunction combined with somatic pathology enables deeper analysis of individual etiopathogenetic processes, which, consequently, will improve the effectiveness of treatment and lead to stable clinical outcomes, regardless of the patient's country of residence.
Restoration of sinus rhythm and left ventricular function in a patient with long-standing persistent atrial fibrillation and chronic heart failure with reduced left ventricular ejection fraction
The objective of the study is to evaluate the effect of sinus rhythm (SR) restoration in a patient with long-standing persistent atrial fibrillation (AF) and chronic heart failure with reduced ejection fraction (HFrEF) of the left ventricle (LV) on the progression of CHF and LV function. The benefits of selecting a "rhythm control" strategy (restoration and maintenance of SR) in patients with long-standing persistent AF and HFrEF remain debated. However, in some cases, even with significantly reduced LV ejection fraction (EF), SR restoration may improve the clinical status, enhance LV systolic function, and reduce CHF severity. As an illustration, we present a clinical case of a patient with long-standing persistent AF and HFrEF where SR restoration resulted in normalized LV EF and alleviated CHF symptoms. In long-standing persistent tachyarrhythmic AF with HFrEF, achieving adequate heart rate control and managing CHF symptoms through pharmacotherapy alone is challenging. A rhythm control strategy in patients with long-standing persistent AF and HFrEF can be successfully implemented, resulting in significant improvement in the functional status, reverse remodeling of the left atrium and LV, and normalization of LV systolic function.
The importance of immunological monitoring in the treatment of refractory membranous nephropathy: clinical case
Primary membranous nephropathy is the most common morphological variant of glomerulonephritis with nephrotic syndrome in the European ancestry. Immunosuppressive therapy is required in most cases of membranous nephropathy treatment. The choice of immunosuppressive drugs and the determination of therapy duration for this nephropathy cause significant difficulties. The role of monitoring immunological parameters in assessing the effectiveness of immunosuppressive therapy and its duration has been poorly studied. The clinical case report examines modern treatment methods for membranous nephropathy with refractory nephrotic syndrome and demonstrates, using a concrete clinical example, the significance of monitoring immunological parameters during immunosuppressive therapy. A 62-year-old female patient had persistent edema of the lower extremities, as well as high levels of proteinuria and autoantibodies to phospholipase A2 receptor (PLA2R). The diagnosis of stage 2 membranous nephropathy was made based on the morphological findings of the renal biopsy. Initial treatment with corticosteroids resulted only in a short-term improvement. Adding cyclosporine to steroid therapy also failed to achieve stable remission of the disease. Two infusions of rituximab (1 g each) in combination with methylprednisolone (16 mg) led to partial remission of the disease by the fifth month (22 weeks later) after administration of the 2nd dose of rituximab, complete remission was achieved by the sixth month (27 weeks later). By this time, the levels of proteinuria and PLA2R antibodies had significantly decreased. However, monitoring of the B-system immune parameters showed increased urinary excretion of IgG and IgA, depending on the damage to the glomerular filtration barrier, which was the reason for the 3rd infusion of rituximab. Laboratory tests conducted 5 months after the administration of the 3rd dose of rituximab confirmed maintained clinical remission and restoration of immunoglobulin levels to the reference values. This clinical observation confirms that the use of rituximab in combination with methylprednisolone is an effective method of refractory membranous nephropathy treatment. This case report demonstrates the possibility of monitoring urinary IgG and IgA levels normalized to urine creatinine level to assess the effectiveness of rituximab therapy and determine its optimal duration.
Effect of coronavirus infection and glucocorticoids on the development of aseptic necrosis of bone
Objective. To identify and characterize the relationship between prior COVID-19 and the development of aseptic necrosis (AN). Materials and methods. The study included patients aged 18 years and older with a confirmed COVID-19 diagnosis (by polymerase chain reaction (PCR) or serological examination) who were diagnosed with AN at least 12 months after recovery. Exclusion criteria were cases of secondary necrosis (due to chronic alcoholism, long-term corticosteroid therapy for other conditions or trauma), as well as patients with rheumatologic or oncologic bone disease. Results. An increased risk of developing AN was identified in patients with severe COVID-19 and/or high doses of glucocorticoids. In some patients laboratory signs of autoimmune disorders (increased levels of antinuclear factor, antiphospholipid antibodies) were observed, which may contribute to the development of bone necrosis. Conclusions. These findings emphasize the necessity for comprehensive assessment of joint complications in patients with severe COVID-19 and the importance of regular monitoring with imaging techniques such as MRI and X-ray for early detection of AN.