No 43 (2015)

Background: Acromegaly is a disease caused by pathologic hypersecretion of growth hormone and insulin-like growth factors. Independent of other cardiovascular disorders, acromegalic cardiomyopathy develops in patients with acromegaly. According to the published data, it manifests by a triad of symptoms, such as hypertrophy, edema and fibrosis of the myocardium. Myocardial fibrosis (diffuse interstitial) develops due to persistent excess of growth hormone and a gradual loss of the heart muscle architectonics. It is difficult to define the rate of cardiac fibrosis in acromegalic cardiomyopathy, because studies in this area are scarce and include small patient numbers.

Aim: To develop an algorithm for cardiac magnetic resonance imaging (CMR) for identification of the key variants of myocardial abnormalities in patients with acromegaly.

Materials and methods: From 2013 to 2015, the CMR was performed in 27 patients aged from 23 to 69 years with a clinical diagnosis of acromegaly. The disease duration ranged from 4 to 38 years. The MRI investigations were performed on a MR scanner General Electric 1.5 T Optima MR450w GEM using cardiac surface coils, with contrast agents with the active substance content of 0.5 mmol / mL, at a dose of 0.3 mL / kg. Synchronization with the heart rhythm was conducted under standard VCG leads. The assessment was done in the standard planes (2- and 4-chamber, short-axis) using sequences of film loops. To identify structural myocardial abnormalities typical for acromegalic cardiomyopathy (hypertrophy, edema and interstitial fibrosis), we used a specialized protocol that in addition to the well known diagnostic sequences included new diagnostic target assessments, such as T1-mapping with a set of 30 indicators of the time inversion).

Results: The semiotics of heart abnormalities in acromegalic cardiomyopathy manifested as myocardial hypertrophy, detected in 20 (74%) patients aged 59–62 years, with disease duration from 5 to 14 years (mild, in 9, moderate, in 9, severe, in 2 cases ) and signs of interstitial fibrosis in 100% of cases. No signs of myocardial edema were found. Calculation of the difference in T1 time values obtained from the mapping of all acromegaly patients showed a change in the relaxation time of various degrees, suggesting the presence of interstitial fibrosis. Initial statistical analysis of the data revealed a significant negative correlation between T1 relaxation time of the left ventricular myocardium and growth hormone levels (r = -0.3929, p < 0.05), as well as a significant negative correlation between the difference in the left ventricular T1 relaxation time before and after administration of the contrast and growth hormone levels (r = -0.4388, p < 0.05).

Conclusion: CMR algorithm including a cine sequence seems to be the most informative in determination of the main types of myocardial abnormalities in patients with acromegaly. It allows an assessment of the functional status and myocardial hypertrophy, black blood sequence and fat saturation that help to identify myocardial edema; T1-mapping technique for the search for diffuse interstitial myocardial fibrosis.

Background: Impractical use of pharmaceuticals is a serious problem of the Russian healthcare system. Implementation of pharmacoeconomic analysis into the logistic technologies of medical organizations may promote the solution of this problem.

Aim: To analyze real-practice data on medical therapy of patients with stable ischemic heart disease (IHD) during their hospital stay for transcutaneous coronary stent placement and coronary artery bypass grafting.

Materials and methods: With the help of a structured form on medical treatment we extracted and analyzed data from 131 clinical records of patients with stable IHD who were hospitalized in 2014 to the Department of Internal Diseases and Department of Cardiovascular Surgery; 60 were patients after stent placement and 71, after coronary artery bypass grafting. We performed an ABC/VEN analysis of their treatment. Groups of pharmaceuticals for VEN analysis were formed according to the Recommendations of Russian National Atherosclerosis Society on Diagnosis and treatment of chronic IHD (Recommendations of Russian National Atherosclerosis Society, 2013) based on European Society of Cardiology guidelines on the management of stable coronary artery disease (ESC guidelines, 2013). We assessed if the treatment administered corresponded to the current Standard of care to patients with stable IHD – SMP No 2.01.216.0 (Russian Federal Standard, 2007).

Results: A mismatch between medical treatment that was performed in the Departments of Internal Diseases and of Cardiovascular Surgery, and that recommended by the Russian Federal Standard (2007), was found. The regimens used include the majority of agents recommended by the Russian National Atherosclerosis Society (2013) and the ESC guidelines (2013). In the Department of Internal Diseases, the mean cost of medical treatment during the whole period of stay in the hospital was 79.6 rubles. The group A agents (those with cumulative cost percentage = 80%) were represented by 9 items from the total of 54. There was a low percentage of medicines that were not indicated for this disease (13 agents, or 9.5% of the total medical costs), and all of them were administered for the treatment of concomitant disorders. In general, medical treatment performed in the Department of Internal Diseases corresponded to the ESC guidelines (2013). The costs of medical treatment during the whole period of stay in the Department of Cardiovascular Surgery was 10 741.9 rubles. The group A included 9 agents from the total of 78 used. Sixty eight per cent of costs were related to pharmaceuticals not having compelling indications (solutions, detoxification agents, agents for prevention of gastrointestinal adverse effects), whereas the costs of vitally important drugs were only 12.3% of the total and those of necessary drugs (including antibacterials), 19.7%.

Conclusion: It is obviously necessary to update the current Russian Federal Standard (2007), with inclusion of data corresponding to the worldwide trends and guidelines of the Russian National Atherosclerosis Society (2013), at least for two patient groups: those after coronary stent placement and after coronary artery bypass grafting. The elaboration of criteria for administration of medical treatment and strict compliance with them in the real practice would allow for controlling of medical treatment costs, to prevent polypragmasia and adverse drug reactions. 

Aim: To assess geometric parameters of the human head based on X-ray computed tomography for construction of the first Russian optical cerebral oxymeter.

Materials and methods: Based on the data obtained by multidetector computed tomography, we retrospectively assessed thickness of the frontal bone squame, adjacent soft tissues and calculated their sum in 100 patients above 50 years of age (50 male and 50 female, mean age 64 ± 8 years). The supraorbital edge of the orbit and the middle line were chosen as the reference points.

Results: The mean frontal squame thickness was6.28 mm (± 1.58) on the right side and6.38 mm (± 1.62) on the left side. The mean thickness of the soft tissues covering the bone at this level was4.39 mm (± 1.21) on the right side and4.41 mm (± 1.22) on the left side. The mean total thickness of the frontal squame bone and soft tissue was11.76 mm (± 2.25) on the right side and11.89 mm (± 2.31) on the left side.

Conclusion: For reliable reproducibility of cerebral oxymetry, geometric characteristics of the area where the sensor will be placed, taking the supraorbital edge and the middle line as reference points. Minimal sums of the mean values and their standard deviations for the frontal bone thickness and soft tissues were measured at the intersection points of3 cm lines perpendicular to these reference points.

Background: Pregnancy is one of the indications for continuous glucose monitoring (CGM). The data on its efficiency in pregnant women are contradictory.

Aim: To compare the results of blood glucose self-monitoring (SMBG) and CGM in pregnant women with previous diabetes mellitus.

Materials and methods: We performed a cross-sectional comparative study of glycemia in 18 pregnant women with previous type 1 (87.8% of patients) and type 2 diabetes (22.2% of patients) with various degrees of glycemic control. Their age was 27.7 ± 4.9 year. At study entry, the patients were at 17.2 ± 6.1 weeks of gestation. CGM and SMBG were performed in and by all patients for the duration of 5.4 ± 1.5 days. Depending on their HbA1c levels, all patients were divided into two groups: group 1 – 12 women with the HbA1c above the target (8.5 ± 1%), and group 2 – 6 women with the HbA1c levels within the target (5.6 ± 0.3%).

Results: According to SMBG results, women from group 2 had above-the-target glycemia levels before breakfast, at 1 hour after breakfast and at bedtime: 6.2 ± 1.6, 8.7 ± 2.1, and 5.7 ± 1.9 mmol/L, respectively. According to CGM, patients from group 1 had higher postprandial glycemia than those from group 2 (8.0 ± 2.1 and 6.9 ± 1.8 mmol/L, respectively, p = 0.03). The analysis of glycemia during the day time revealed significant difference between the groups only at 1 hour after dinner (7.1 ± 1.4 mmol/L in group 1 and 5.8 ± 0.9 mmol/L in group 2, р = 0.041) and the difference was close to significant before lunch (6.0 ± 2.2 mmol/L in group 1 and 4.8 ± 1.0 mmol/L in group 2, р = 0.053). Comparison of SMBG and CGM results demonstrated significant difference only at one timepoint (at 1 hour after lunch) and only in group 1: median glycemia was 7.4 [6.9; 8.1] mmol/L by SMBG and 6 [5.4; 6.6] mmol/L by CGM measurement (р = 0.001). Lower median values by CGM measurement could be explained by averaging of three successive measurements carried out in the period of rapid changes of glycemia.

Conclusion: The achievement of control of diabetes by HbA1c doesn't necessarily reflect current achievement of the target glycemic levels. As long as there was no significant difference in glycemia measured by SMBG and CGM, we conclude that CGM doesn't have any advantage over routine frequent SMBG in pregnant women.

The annual rate of deep vein thrombosis in general population is from 5 to 9 cases per 10 000, whereas for venous thromboembolism (deep vein thrombosis and pulmonary embolism taken together) amounts to 14 cases per 10 000. To improve longterm results of therapy for thrombosis of deep veins of the lower extremities, it is important to restore venous function and outflow. Anticoagulant therapy with low weight or non-fractionated heparin preparations remains the most widely used method of management. However, total or partial thrombosis resolution under anticoagulant treatment is achieved only in 4 and 14% of cases, respectively. Thrombolysis allows for early resorption of the thrombus by means of a minimally invasive procedure with lower risk of complication. After the venous flow is restored, the aim of treatment is to prevent damage to the venous valves, venous hypertension and repeated thrombosis with development of the post-thrombotic syndrome. Compared to anticoagulation, systemic thrombolysis has the benefit of more rapid clot resorption and less damage to the venous valve. One of its serious limitations is a high bleeding risk related to higher doses of the drug administered through a peripheral vein catheter. Therefore, selective intra-clot administration of thombolytics (direct catheter thrombolysis) has been suggested as an alternative. For more effective therapy with the use of lower doses of thrombolytics, the so called pharmaco-mechanical thrombectomy has been developed. Venous stenosis hindering the venous outflow is frequently seen after direct catheter or pharmaco-mechanical thrombolysis. Angioplasty with stent placement is recommended in the cases with residual venous abnormality after successful thrombolysis and thrombectomy. 

Wilms' tumor is the most common primary malignant renal tumor. It is paradigm for comprehensive treatment of malignant solid tumors in children. Typically, children with this disorder are initially seen with abdominal distention, palpable masses or due to fever of unknown origin. Atypical tumor symptoms can be caused by complications, making it difficult to diagnose the disease. We present three clinical cases of Wilms' tumor in young children. Emergency multidetector computed tomography and magnetic resonance imaging provided the surgeon with sufficient information to perform an urgent radical resection.

Pleuropulmonary blastoma is a rare primary malignant tumor originating from lungs and/or pleura. It is more frequent in young children and differs from other lung neoplasms by a number of histopathological particulars. We present a clinical case of such tumor in a 3-year-old child. Initially, the disease was diagnosed as pleuropneumonia, however, computed tomography revealed a tumor originating from mediastinum. Current data indicates that diagnostics of pleuropulmonary blastoms is difficult even with the use of a full range of radiation assessment methods and participation of qualified specialists.

We present a clinical observation of a pathological fracture of the spine in a patient with ankylosing spondylitis (Bechterew's disease). The results of a comprehensive radiological assessment (X-ray, multidetector computed tomography, magnetic resonance imaging), which enabled the differential diagnosis with a tumor and inflammatory processes and to determine a management strategy.