Vol 50, No 8 (2022)

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Chronic glomerulonephritis and pregnancy: predictors of preterm birth

Gubina D.V., Prokopenko E.I., Nikol'skaya I.G.


Background: Chronic kidney disease (CKD) in pregnant women, with one of its most important causes being chronic glomerulonephritis (CGN), increases the incidence of adverse perinatal outcomes and gestational complications, including preterm birth (PB). Being the main cause of infant morbidity and mortality, PB has serious medical and social significance.

Aim: To identify clinical predictors and develop a predictive model of PB in pregnant women with CGN.

Materials and methods: A retrospective/prospective study included 122 CGN patients, whose 128 pregnancies resulted in childbirth from January 2009 to November 2022. Eighty-eight pregnancies were in the patients with CKD stage 1, 15 in stage 2, 21 in stage 3a, 3 in stage 3b, and one in stage 4. One hundred and nine (109) patients (115 pregnancies) delivered on term (at least 37 weeks of gestation) and were included into the group of term deliveries, whereas 13 women with 13 pregnancies had PB within the range of 22 weeks to 36 weeks 6 days. In the patients of both groups, we assessed nephrological and obstetric history, proteinuria and arterial hypertension at baseline and during pregnancy, complications of the index pregnancy, such as preeclampsia (PE) and severe PE, anemia, urinary tract infections, acute kidney injury, placental insufficiency, and cervical insufficiency. Binary logistic regression was used for prediction modeling of PB in women with CGN.

Results: The proportion of PB in total cohort of the CGN patients was 10.2%. PB was spontaneous only in 2/13 (15.4%) cases, while in the rest of 11 pregnancies (84.6%) the delivery was induced due to maternal and fetal indications. Six independent predictors of PB were identified: body mass index, CKD stage, history of non-developing pregnancies, proteinuria during pregnancy ≥ 1 g/day, PE and placental insufficiency. The predictive model had sensitivity of 76.9%, specificity 99.1%, diagnostic efficiency 96.9%, positive predictive value 90.9%, and negative predictive value – 97.4%.

Conclusion: Predicting PB and targeting modifiable factors associated with PB may improve pregnancy outcomes in patients with CGN.

Almanac of Clinical Medicine. 2022;50(8):463-470
pages 463-470 views

The impact of obesity on COVID-19 outcomes in hospitalized patients

Markova T.N., Anchutina A.A., Bodranets A.A.


Background: Obesity is recognized as a risk factor for adverse outcomes in patients with COVID-19. However, a number of studies, including an analysis of the Federal Registry of Diabetic Patients (Russian Federation), have not identified any significant effect of obesity on mortality in COVID-19. Therefore, the role of obesity, assessed by body mass index (BMI) and waist circumference (WC), as a risk factor for an unfavorable course of coronavirus infection remains disputable.

Aim: To assess the impact of obesity on the severity and outcomes of coronavirus infection in the Russian population of hospitalized patients.

Materials and methods: This was a single center, retrospective, observational study in 367 patients with the polymerase chain reaction (PCR)-confirmed diagnosis of COVID-19 hospitalized to the in-patient department from April 2020 to November 2021. The first group included 185 patients with obesity (BMI ≥ 30.0 kg/m2); the second group consisted of 182 patients without obesity (BMI < 30.0 kg/m2). Prevalence of comorbidities, clinical and laboratory parameters, and computed tomography results were assessed in both groups. WC was measured in 100 patients.

Results: In this Russian population of hospitalized patients with COVID-19, obesity (BMI ≥ 30.0 kg/m2) didn't increase the probability of death both in the general sample (odds ratio (OR) = 1.31; 95% confidence interval (CI) 0.90–1.92, p = 0.164) and in the patients with type 2 diabetes (OR = 1.0; 95% CI 0.59–1.7, p = 0.997) or without diabetes (OR = 1.3; 95% CI 0.71–2.39, p = 0.392). However, obesity was associated with a 1,7-fold increase of the risk of severe COVID-19 (95% CI 1.13–2.59, p = 0.010). Morbid and abdominal obesity (according to World Health Organization and International Diabetes Federation criteria) had no significant impact on the death rate. WC of ≥ 101 cm, regardless of the patient’s gender, was associated with a 4,9-fold increase of the risk of death (95% CI 1.45–16.42, p = 0.012).

Conclusion: Obesity didn’t show any significant effect on mortality, but increased the chance of severe course of COVID-19 infection. Abdominal obesity (WC ≥ 101 cm) was a more significant factor in predicting of a fatal outcome, than BMI.

Almanac of Clinical Medicine. 2022;50(8):471-480
pages 471-480 views

The results of systemic thrombolytic therapy for acute ischemic stroke in women and men depending on the stroke risk factors

Kotov S.V., Belkina S.N., Isakova E.V., Kotov A.S.


Background: Systemic thrombolytic therapy (STLT) with alteplase is the method of choice in all patients with acute ischemic stroke (IS) within the first 4.5 hours after the symptom onset. There is a noticeable difference between men and women in the clinical characteristics and results of stroke treatment; however, results of studies have been contradictory.

Aim: To evaluate the efficacy of STLT with alteplase in women compared to men, depending on the presence of some risk factors for stroke.

Materials and methods: This open-label prospective observational non-interventional cohort study of STLT in IS included 209 patients (102 women, the main group, and 107 men, or the comparison group) aged 32 to 86 years. All patients received STLT with alteplase within 4.5 hours from the onset of IS symptoms. The primary endpoint of the study was 28-day survival, and the secondary endpoint was the achievement of mobility independence (0 to 2 points by the modified Rankin Scale (mRS)).

Results: The demographic and clinical patient characteristics of both groups were comparable, but women were on average 5 years older than men (p = 0.003). The index IS was not the first one in 31.4% of women and 23.4% of men (p > 0.05). There were no significant differences in the severity of stroke and the timing of STLT. Men had a high mortality rate in the acute period of IS, but the difference was non-significant. PST-STLT hemorrhagic transformation was more common in men, with the difference being non-significant (χ2 0.743, p = 0.389). Women were more likely to have type 2 diabetes mellitus (DM2) (37.3% and 20.6%, respectively, χ2 7.111, p = 0.008). In women, there was a trend towards better symptom regression by about 1 point (p = 0.129). The women with DM2 had a 13% higher survival than men (p = 0.038). The numbers of patients achieving independence (0–2 points on the mRS scale) by Day 28 was not different (56 women and 52 men). No between-groups differences were found in the numbers of patients with arterial hypertension and atrial fibrillation. Only 13 women (12.75%) and 21 men (20%) had a normal body mass index, while 56.3% of women and 46.7% of men had obesity 2 or 3 grades, with the gender differences being non-significant.

Conclusion: In women, who have received STLT in the acute period of IS, the death rates and the functional outcomes were non-inferior to those in men, despite their older age, hyperglycemia in the acute period and past history of DM2. The risk factors for stroke in women, compared to men, could be the potential cause of more frequent IS recurrence (every third case in women and every fourth in men was recurrent). Despite a number of negative factors (age, obesity, metabolic syndrome, hyperglycemia, DM2, atrial fibrillation), there was a trend towards better outcomes of STLT in women.

Almanac of Clinical Medicine. 2022;50(8):481-489
pages 481-489 views


Development of three endocrinopathies under nivolumab therapy

Glibka A.A., Mazurina N.V., Gridnev D.I., Sarantseva K.A., Troshina E.A.


Active implementation of immune checkpoint inhibitors into oncology practice leads to an increase in numbers of observed immune-mediated adverse events, including various endocrinopathies. The focus is on multiple endocrine gland involvement because their predictors are unclear.

The paper describes a clinical case of a patient with central cancer of the right lung, who had been administered immune therapy with anti-PD-1 monoclonal antibody (nivolumab). Under this treatment, three endocrine immune-mediated adverse events developed without any concomitant problems from other organs and body systems. The most interesting was the occurrence of adrenal insufficiency and fulminant diabetes mellitus, while, unlike hypothyroidism, which also developed in this patient, those two have been significantly less often described and up to now their incidence, prevalence and association with a certain subgroup of immune checkpoint inhibitors have not been identified. Despite multiple endocrine organ involvement and taking into account positive effects of the anti-tumor treatment, as well as titration of the corresponding hormonal replacement therapy, treatment with nivolumab was continued.

Patients treated with immune checkpoint inhibitors require a multidisciplinary team approach including an endocrinologist, because of the potential multiple endocrinopathies, including life-threatening.

Almanac of Clinical Medicine. 2022;50(8):490-496
pages 490-496 views

A clinical observation of recurrent painful ophthalmoplegic neuropathy in a 49-year old female patient

Ryabchenko A.Y.


Recurrent painful ophthalmoplegic neuropathy is a rare clinical syndrome, included into the International Classification of Headache Disorders, 3rd edition, and characterized by recurrent headache episodes associated with dysfunction of one or more ocular motor nerves. The diagnosis implies mandatory exclusion of other potential causes of the symptoms. The paper presents a clinical case of a 49-year old female patient with a unilateral headache paroxysms and subsequent paresis of the oculomotor nerve. A thorough clinical assessment, with neuroimaging (brain magnetic resonance imaging and magnetic resonance angiography of arteries and veins of the head) showed no morphological abnormalities that could cause clinical symptoms of oculomotor neuropathy. Her past history was remarkable for a similar episode of prolonged unilateral headache and oculomotor paresis about 10 years before, which were at that time considered as an acute cerebrovascular accident. Thus, two episodes of similar clinical signs of painful neuropathy, the absence of other possible causes of the disease, and the complete regression of symptoms after treatment (ibuprofen and gabapentin) confirmed the diagnosis of recurrent painful ophthalmoplegic neuropathy.

Almanac of Clinical Medicine. 2022;50(8):497-502
pages 497-502 views

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