Implementation of a “seamless” model of providing specialized medical care to patients with heart failure

Kobalava Z.D., Tolkacheva V.V., Vatsik-Gorodetskaya M.V., Cabello-Montoya F.E., Nazarov I.S., Galochkin S.A.


Heart failure (HF) is a widespread disease and tends to increase. Despite the possibilities of modern therapy, the prognosis of patients with HF remains unfavorable. Foreign experience shows that the creation of specialized heart failure clinics improves the quality of care for patients with HF, reduces the frequency of repeated hospitalizations and death of patients. The Russian Federation has gained experience in creating such clinics, in particular, in Nizhny Novgorod, Ufa, St. Petersburg and a number of other cities. The article describes the organization of the work of the Center for HF on the basis of a multidisciplinary hospital in Moscow in period 01.11.2020-01.12.2022. The database included 2,400 patients hospitalized due to acute decompensation of chronic HF (ADCHF). The leading triggers of ADCHF in the studied patient population were an episode of atrial fibrillation/flutter (37 %), low adherence to treatment (25 %) and uncontrolled hypertension (17 %), exacerbation of concomitant diseases (11 %), infection (4 %). In 6 % of patients, the leading trigger could not be identified. The hospital stage included 950 (39.5 %) patients who, in the first 24 hours from the moment of hospitalization, underwent standard physical, laboratory and instrumental examination, including lung ultrasound, NT-proBNP, liver fibroelastometry, VEXUS protocol study, bioimpedance analysis of body composition, of which 496 (20.5 %) people passed the same studies at discharge. In the structure of patients hospitalized with ADCHF who were included in the hospital follow-up stage (n=950), patients with preserved (HFpEF) 42.5 % (n=404) and reduced ejection fraction (HFrEF) prevailed 36 % (n=342), patients with a mildly reduced (HFmrEF) ejection fraction were found in 21.5 %. 1,552 (64.5 %) patients refused additional studies and visits to the CH center, but agreed to outpatient follow-up in the form of telephone contacts. In 370 (15.4 %) patients, contact was lost after discharge. 240 (10 %) patients actively visit the HF center with a comprehensive assessment of congestion and correction of therapy at each visit. Conclusion. There are two stages in the treatment of patients with chronic HF. The first stage is hospital, the second one is outpatient. It is important not to make omissions in the prescribed drug therapy, which can lead to a fatal outcome. To this end, it is necessary to introduce a “seamless” model of medical care for patients with chronic HF, when the patient comes under the supervision of a multidisciplinary team that carries out timely monitoring.

RUDN Journal of Medicine. 2023;27(2):141-154
pages 141-154 views

Arterial hypertension in young adults

Bazdyreva E.I., Shavarova E.K., Ezhova N.E., Kirpichnikova E.I., Kobalava Z.D.


Arterial hypertension (AH) is associated with the development of pathological changes in target organs, which leads to an increase in morbidity and mortality. The aim of the review was to discuss the peculiarity of AH in young people, in particular risk factors for developing AH, associations between the risk of cardiovascular events and elevated blood pressure in young adults, blood pressure phenotypes in young people, the role of traditional cardiovascular diseases risk factors in young people with AH, features of target organ damages in young people with AH and optimal blood pressure for target organ protection. Threshold values of blood pressure, from which the cycle of pathological changes starts, have not been finally determined, however, it is likely that they are significantly lower than the blood pressure values that are currently used to diagnose AH n in Europe and Russia. Reclassification of AH using more strict criteria in the United States resulted in an increase in the prevalence of AH from 29 % to 43 %, and affected mainly young people. Obesity, increased daily sodium excretion, increased consumption of meat products, dyslipidemia, hyperinsulinemia, hyperuricemia, high levels of depression and low social status are among the potential risk factors for developing AH at a young age, while a low-salt diet, eating a large amount of plant foods, high in carotenoids and folate, and a high level of physical activity may have a preventive effect on the development of AH. The results of recent studies indicate a high prevalence of AH, including masked, in young people, which often remains underestimated in real clinical practice. The strategy for the treatment of AH in young patients has not been determined, which is associated with an insufficient evidence base. Studies are needed to identify additional arguments for initiating or withholding antihypertensive therapy in this population, including the study of early signs of hypertension-associated target organ damage. Conclusion. The results of recent studies indicate a high prevalence of hypertension, including masked, in young people, which often remains underestimated in real clinical practice. Further research is required to identify additional arguments for initiating or withholding antihypertensive therapy in this population, including the study of early signs of hypertension-associated target organ damage.

RUDN Journal of Medicine. 2023;27(2):155-166
pages 155-166 views

Aortic-brachial stiffness mismatch as potential marker of subclinical arterial damage in patients with rheumatoid arthritis

Troitskaya E.A., Velmakin S.V., Goreva L.A., Kobalava Z.D.


Aortic-brachial stiffness mismatch is a potential new marker of a subclinical vascular damage that has never been studied in patients with rheumatic diseases. The aim of the study was to assess the frequency of arterial stiffness mismatch in rheumatoid arthritis (RA) and to evaluate its clinical associations. Materials and Methods. The study group included 85 patients with RA (males 22.4 %, aged 59.7 ± 14.3 years, hypertension in 65 %, mean disease activity score (DAS-28 (C-reactive protein) 3.7 ± 1.1), and the control group included 40 subjects matched by gender, age and risk factors. The study methods included measurements of clinical and ambulatory brachial and aortic blood pressure (BP) (BPLab-Vasotens), arterial stiffness parameters parameters (applanation tonometry, SphygmoCorAtCor), cardio-ankle vascular index (VaSera) and cardio-vascular risk assessments using the SCORE, American College of Cardiology/American Heart Association (ACC/AHA) 2013 pooled cohort equations and QRisk2 scoring systems. The arterial stiffness gradient was calculated as a ratio between carotid-femoral (cf) and carotid-radial (cr) pulse wave velocity, and its elevation of ≥ 1 was considered as arterial stiffness mismatch. A p-value of < 0.05 was considered significant. Results and Discussion. The mean stiffness gradient in RA patients without and with hypertension was 1.1 ± 0.1 and 1.4 ± 0.4, respectively (р < 0.001); in controls, 0.99 ± 0.2 and 1.3 ± 0.3, respectively (р < 0.001). The frequency of stiffness mismatch in the RA group was significantly higher compared to the controls in the whole study population (88.2 % vs 65 % (р = 0.002)) and in both normotensive and hypertensive subgroups (76.7 % vs 43.8 % (p = 0.03), and 94.5 % vs 79.2 % (p = 0.04), respectively). The same trend was observed in the subgroups with normal carotid-femoral pulse wave velocity: arterial stiffness mismatch was present in 82.1 % of RA patients vs. 51.9 % control subjects (p = 0.004). The stiffness gradient was associated with age (r = 0.63), hypertension duration (r = 0.56), cardio-vascular risk by the ACC/AHA 2013 (r = 0.69) and Qrisk2 (r = 0.7) scoring systems, nocturnal aortic systolic BP (r = 0.53), cardio-ankle vascular index (r = 0.60) and diurnal index of brachial systolic BP (r = -0.4). Significant differences in stiffness gradient values were observed in the subgroups based on elevation of aortic systolic BP and pulse wave velocity above individual reference values, aortic pulse pressure > 50 mmHg, cardio-ankle vascular index > 9, presence of high cardio-vascular risk, masked and nocturnal hypertension, and non-dipping. Conclusion. Patients with RA are characterized by higher frequency of arterial stiffness mismatch compared to controls, irrespective of the history of hypertension or the values of carotid-femoral pulse wave velocity. Arterial stiffness mismatch is associated with unfavorable 24-h BP profile, higher frequency of nocturnal hypertension and cardio-vascular risk.

RUDN Journal of Medicine. 2023;27(2):167-181
pages 167-181 views

Respiratory system functional state in patients after the left ventricle geometric reconstruction followed by conventional respiratory rehabilitation

Lobacheva G.V., Alshibaya M.M., Mamalyga M.L., Zatenko M.A., Danilov S.A., Arzumanyan M.A.


Relevance. Post-infarction left ventricular aneurysm (PILVA) is the most severe complication of myocardial infarction in patients with ischemic heart disease. Systemic hemodynamic disorders in PILVA can lead to respiratory dysfunction before surgery and worsen cardiorespiratory failure in the postoperative period. Despite modern opportunities for early diagnosis and treatment of respiratory dysfunction, effective methods of postoperative respiratory function recovery have not yet been developed for patients after the left ventricle geometric reconstruction (LVGR). The aim: to investigate the cardiorespiratory status of patients before and after LVGR and to evaluate the effectiveness of conventional respiratory rehabilitation for this category of patients. Materials and Methods. The study involved 43 patients who underwent two types of surgeries: 1) coronary artery bypass grafting (CABG), and 2) CABG with LVGR. Patients were divided into two groups: group I - patients after CABG, and group II - patients after CABG with LVGR. Data collection was carried out in three stages: I - before surgery, II - on the 2nd day after surgery, and III - on the 10th day after surgery. Conventional respiratory rehabilitation was conducted in both groups. Results and Discussion. The results showed a deterioration in preoperative respiratory parameters (FVC [10.3 %, p = 0.039]; FEV1 [11.9 %, p = 0.027]) and cardiac dysfunction (EF [30.2 %, p < 0.001]; EDV [56.4 %, p < 0.001]) in group II compared to group I. By the time of discharge, no positive dynamics were observed in most of the examined spirometry parameters in group II. In group I, dynamics were noted in almost all analyzed parameters (p < 0.05). Analysis of the desaturation index (DI) revealed the presence of pronounced sleep-disordered breathing in all groups during the second postoperative night. On the 10-12th postoperative day, DI in group I reached the preoperative level, while in group II this index remained elevated by 1.56 times (p = 0.006). Conclusion. Patients after LVGR have more pronounced oxygenation reduction, which is caused by both impaired patency at the level of the proximal and middle bronchioles and restrictive disorders associated with increased extracellular fluid volume. This largely forms the pathogenetic basis for the development of respiratory complications in the early postoperative period.

RUDN Journal of Medicine. 2023;27(2):182-194
pages 182-194 views

Key role of histological and PCR studies in the differential diagnosis of heart valve disease in Takayasu’s arteritis, infective endocarditis and myxomatous degeneration

Pisaryuk A.S., Kotova E.O., Moiseeva A.Y., Domonova E.A., Tsimbalist N.S., Meray I.A., Safarova A.F., Bogdanova T.G., Tolokonnikova N.E., Kobalava Z.D.


Aortic valve lesion is a common cardiopathy, which may have very diverse causes, from degenerative, congenital and infectious diseases to autoimmune conditions. We present a rare case of Takayasu arteritis and severe heart lesion due to the myxomatous degeneration of the aortic and mitral valve cusps associated with the development of infectious endocarditis (IE) complicated by abscess, fistula, valve perforation and recurrent acute decompensated heart failure in a young female patient. A combined use of histopathological and PCR analyses of valve tissues was critically important for differential diagnosis of the valve lesions, as it made it possible to identify the true cause of the structural cardiopathy associated with myxomatous degeneration and a prior IE. The presence of Takayasu arteritis has played an indirect though apparently decisive role by creating conditions for the development of immunosuppression and determining the disease severity and progression rate.

RUDN Journal of Medicine. 2023;27(2):195-206
pages 195-206 views


Vitamin D deficiency conditions in children in the antenatal period from the perspective of prognosis and prevention

Bogdanova S.V., Ilyenko L.I., Gureev A.N.


Relevance. Irrational nutrition of a pregnant woman, unjustified drug load, inactivity, insufficient insolation, constitute a high risk of vitamin D deficiency. Vitamin D deficiency conditions correlate with the frequency of the pathological course of pregnancy and childbirth, dictating the need for timely correction from the standpoint of optimizing care for the child population. The aim of the study - evaluation of the possibility of predicting vitamin D deficiency conditions in children in the antenatal period using a complex of medical and statistical analysis methods. Materials and Methods. A prospective cohort study of 248 mother-child pairs was conducted. Pregnant women: the main group (148) - receiving vitamin D prophylactically at a dose of 1000 MG (Aquadetrim) when registering. The comparison group was those who did not receive vitamin D (100). Inclusion criteria: absence of exacerbation of chronic pathology, allergic reactions, malabsorption syndrome, obesity, diabetes, taking HA, antiepileptic drugs, hyperparathyroidism, severe infections. All women were examined at the end of the 3rd trimester and the postpartum period. Children were observed of 248 children born to pregnant women of two groups. All children were observed with the informed consent of their parents. The duration of observation is up to 3 years. An assessment of the somatic status and general clinical examinations were carried out. Risk factors were assessed using mathematical and statistical methods to compile a prognostic scenario for the development of vitamin D deficient conditions. Results and discussion. Based on the data obtained using the statistical analysis method, it was found that the pathological course of pregnancy and childbirth in women who received vitamin D during pregnancy according to the RR data, AtR were significantly less frequent. Newborns of the main group had higher mass-growth indicators, significantly less often insufficiency, vitamin D deficiency, neurological symptoms; subsequently, a lower incidence of allergic diseases, acute respiratory viral infections, changes in the bone system. Conclusions. Evaluation of the possibility of predicting vitamin D deficiency conditions in children in the antenatal period using a complex of medical and statistical analysis methods reduces the risk of: pathological course of pregnancy, childbirth, the frequency of vitamin D deficiency and deficiency in newborns, affecting mass-growth indicators at birth, neurological symptoms, allergic diseases, respiratory infections in infancy, changes in the bone system in young children. Prevention of the development of vitamin D deficiency conditions in the antenatal period makes it possible to optimize the care of the child population.

RUDN Journal of Medicine. 2023;27(2):207-217
pages 207-217 views

Iron deficiency conditions prediction and prevention in children

Ilyenko L.I., Bogdanova S.V., Gureev A.N., Lazareva S.I., Semashina G.A., Obelchak E.V., Ponomarev D.A., Chepurnaya J.Y.


The relevance of iron deficiency issues is due to the high frequency and tendency to steady growth, affecting the quality of life of the population. Pregnant, lactating women and young children are at high risk of developing iron deficiency conditions. Among pregnant women, a direct correlation was found between iron deficiency in the early stages of gestation and the pathological course of pregnancy and childbirth, lower indicators of physical, psychomotor development of children. Materials and methods. A prospective cohort study of 248 mother-child pairs was conducted. Pregnant, lactating women: the main group-women who received iron preparations during registration-106 persons, the comparison group-those who did not receive iron preparations-142. Inclusion criteria: absence of exacerbation of chronic pathology, allergic reactions, gastrointestinal pathology, infectious diseases. The women were examined at the end of the 3rd trimester and the postpartum period. Catamnestic observation was carried out for 248 children born to pregnant women. All children were observed with the informed consent of their parents. The duration of observation was up to a year. The children of the main group (106) and the comparison group (142) were singled out. Children of the main group on natural feeding (98) were divided into two subgroups. The first subgroup - 47 children whose mothers received iron preparations during lactation, the second subgroup - 51 children whose mothers did not receive iron subsidies. An assessment of the somatic status, a general clinical examination was carried out. Results and Discussion.Based on the data obtained using the statistical method of analysis, it was found that iron deficiency in the antenatal period significantly increased the frequency of premature birth, caused a deficiency of birth weight, heart disease, and led to a high frequency of viral infections in pregnant women. In newborns, from mothers who did not receive the iron preparation, a high frequency of latent iron deficiency (LID) and iron deficiency anemia (IDA) was noted. Newborns from the comparison group, according to the results of laboratory diagnostics, were treated with LID and IDA, however, lower indicators of physical development, NPR remained until 6 months. In the postnatal period, there was a direct correlation between the prophylactic intake of iron preparations by a nursing mother and the occurrence of latent iron deficiency and IDA in a child. Conclusion. The data obtained allow us to speak about the high effectiveness of preventive iron supplementation by a pregnant and lactating woman, to reduce the risk of pathological pregnancy and childbirth, affecting the indicators of physical and neuropsychic development (NPD) of a newborn and an infant. Even with the timely elimination of iron deficiency in a newborn, the delay in physical and NPR is noted up to 6 months. The analysis of the effect of iron deficiency in pregnant and nursing mothers on the course of the antenatal period, childbirth and the state of the child’s health dictates the need for prevention from the standpoint of a personalized approach.

RUDN Journal of Medicine. 2023;27(2):218-227
pages 218-227 views


Evaluation of the efficiency of the expert medical decision making system in diagnosis acute appendicitis

Burnevich S.Z., Maslenko N.S.


Relevance. Timely diagnosis is the basic criterion for the quality of medical care in emergency department. One of the promising directions in the prevention of diagnostic errors is the use in clinical practice of the expert decision support system (EDSS). The aim of this study was a comparative analysis of the diagnostic efficiency of EDSS in acute appendicitis (AA) at various stages of the differential diagnosis of acute abdominal pain (AAP). Materials and methods. The study performed a retrospective analysis of the diagnostic results of 150 patients with various forms of AA, followed by the processing of structured clinical, laboratory and instrumental data using the original version of EDSS. Results and Discussion. It has been established that EDSS unidirectionally and sequentially models the stages of a standard diagnostic program for examining a patient with AAP at all levels of automated assessment of symptoms and signs of AA. Depending on the final parameters of the indication, the EDSS makes it possible to differentiate the variants of AA clinical scenarios with the identification of categories of diagnostic complexity that occurred in surgical practice. The data of relevance and validity of EDSS in the differential diagnosis of AAP are presented. The role of the expert system for the intensification of the doctor’s clinical reasoning and the prevention of diagnostic errors in emergency abdominal surgery is noted. Conclusion. The data obtained indicate a comparable diagnostic efficiency of the proposed version of EDSS with the accuracy of the diagnosis of a surgeon. The results of the preclinical use of EDSS allow the clinician to recommend its use in the format of an interactive “cognitive assistant” in case of possible difficulties and doubts in the differential diagnosis of AAP.

RUDN Journal of Medicine. 2023;27(2):228-245
pages 228-245 views

Urgent total pancreatoduodenectomy for profuse gastro-intestinal bleeding caused by renal cancer metastases to the pancreas

Mylnikov A.G., Klimov A.E., Kurbanniyozov T.S., Bujmestru N.V., Chernjaeva A.A., Gusarova T.A.


Renal cancer (RC) can spread to different organs, metastatic damage of the pancreas is quite rare. But, in contrast of primary and other metastatic malignant tumors, pancreatic RC metastases can be resectable in 80 % of cases with nearly 90 % 5-year survival rate. Pancreatic oncologic surgery includes 3 different types of resection: distal pancreatic resection, pancreatoduodenal resection and total duodenopancreatectomy. The last type is the most extensive procedure, incorporates except of total removal of the pancreatic gland, total excision of duodenum and, in some cases, partial gastrectomy. In surgery of pancreatic tumors using of total duodenopancreatectomy is relatively rare (6,7-12,3 %). And in spite of low mortality (5-6,25 %) in recent years, whole removal of the gland inevitably leads to severe metabolic changes such as complete exocrine insufficiency and unstable insulin-depended diabetes mellitus which need lifetime medical correction. Gastrointestinal bleeding from pancreatic metastases of RC as a disease complication occurs quite rare and appears due to invasion of cancer tissue located in the pancreatic head to duodenal mucosa and then ulcerated. There are few single observations or little series (2-4 cases) described in literature. Pancreatoduodenal resection in such cases is the main type of surgical intervention. Now we present a case of successful urgent total duodenopancreatectomy, performed for recurrent profuse gastrointestinal bleeding from pancreatic head metastasis of RC invaded duodenum after previously radical nephrectomy. During the operation several cancer nodes in the pancreatic body and tail were found that defined the total gland removal. Postoperative period proceeded uneventfully and the patient was discharged on 15th day. Uniqueness of this case is that emergency total duodenopancreatectomy was successfully done for profuse gastrointestinal bleeding as the only possible chance for cure. We have not found similar reports in the available literature.

RUDN Journal of Medicine. 2023;27(2):246-253
pages 246-253 views


Diagnostics and prevention of sports-related traumatic brain injury complication

Shevelev O.A., Smolensky A.V., Petrova M.V., Mengistu E.M., Mengistu A.A., VatsikGorodetskaya M.V., Khanakhmedova U.G., Menzhurenkova D.N., Vesnin S.G., Goryanin I.I.


Sports-related traumatic brain injuries (TBI) accounts for up to 20 % of all injuries that are obtained by athletes and its incidence rises annually due to rise in population involving in sports, growing popularity of extreme sports and high level of motivation to achieve record results among young sportsmen. The aim of the review is to present the potential benefits of using microwave radiothermometry and craniocerebral hypothermia technologies in sports-related TBI. The review considers most common form of traumatic brain injury in athletes - mild TBI, which in turn can provoke a wide range of complications and negative consequences in near and delayed periods after the injury. The main shortcomings of programs for complication prevention in treatment and rehabilitation of athletes after TBI are considered, which do not take into account the peculiarities of injury mechanisms, its significant differences from household, road or criminal injuries with brain damage. Lack of objective methods of instrumental diagnosis for injury severity is also described. In addition, pathophysiological component characteristics of sports TBI is accentuated: frequency of repetition, increasement of brain and body temperature, peripheral redistribution of blood flow and hypocapnia, which significantly affects cerebral blood flow. Based on the analysis of the available scientific literature, it is elicited that TBI is an independent cause of cerebral hyperthermia development, which significantly aggravates the consequences of the injury. Conclusions. The authors propose an innovative way to use microwave radiothermometry method as a diagnostic tool for sports-related TBI. In addition, the review highlights the main recommendations for complications prevention by using craniocerebral hypothermia technology, which reduces overall physical and cerebral hyperthermia, and augments the resistance of cerebral cortex neurons to hypoxia and trauma. However, the authors believe that the described approaches in sports medicine are not used purposefully due to lack of awareness of sports team doctors and coaches.

RUDN Journal of Medicine. 2023;27(2):254-264
pages 254-264 views


Innovator from Novatorovs` street: the life of a scientist, the fate of a devotee

Sharapova O.V., Ilyenko L.I., Mukhina J.G., Gureev A.N., Zubareva E.A., Zhitova T.A., Bogdanova S.V.


The article is dedicated to the memory of a Russian scientist, doctor, teacher, dean of the Faculty of Pediatrics, who stood at the origins of perinatal medicine from the standpoint of an innovative approach in diagnosis, therapy, prevention and training of future doctors. The aim of the article is to study the biography of the outstanding Russian scientist Maria Fedorovna Deshchekina, from the standpoint of a significant contribution to perinatal medicine. In the course of writing the article, comparative historical and analytical methods of historical and medical research were used using archival data from the 4th maternity hospital on Novatorov Street, house 3, Moscow, where Maria Fedorovna worked, memories of colleagues, students and relatives. The main results are the presentation of modern achievements in pediatrics on the foundations laid by Maria Fedorovna, who has high professionalism and innovative approaches. Medicine of the XXI century opens up wide opportunities in forecasting, prevention, therapy and rehabilitation. The modern stage of medical science development is based on powerful technological progress, advanced pharmacological research, breakthroughs in the field of genetics and nanotechnology. But behind the high achievements of the present are our dear Teachers, who laid the foundation for the future of medicine with their high professionalism. We should not lose these classical views, works, and approaches. The life and fate of the outstanding Russian doctor Maria Fedorovna Deshchekina is a vivid example of loyalty to the profession and service to people. In 2022, on the centennial anniversary of her birth, a conference was held and a book dedicated to the memory of Maria Fedorovna, a unique doctor, scientist, teacher, organizer, was published at the Federal State Educational Institution of the Russian Ministry of Health named after N.I. Pirogov. The founder of the conference is a student of Maria Fedorovna - Ilyenko Lidiya Ivanovna. Maria Fyodorovna’s life is closely connected with the 2nd MOLGMI (the Federal State Educational Institution of the Russian Ministry of Health named after N.I. Pirogov), the Department of Hospital Pediatrics and Maternity hospital No. 4. Moscow. She went from student to professor, head of the department, dean of the Pediatric Faculty. The results of her activities have developed into a certain concept, which we still adhere to. As Dean, Maria Fedorovna proved herself to be a talented teacher, psychologist and organizer, paying great attention to improving the pedagogical skills of teachers. It was during this period that methodological work was elevated to the rank of scientific and methodological, which led to a series of articles written in collaboration with the Department of Pedagogy. Neonatologists, obstetricians-gynecologists, neurologists and pediatricians know the name of Maria Fedorovna well, since she first described somatic manifestations of birth trauma and presented them in the form of syndromes. This classification is still in effect today and greatly facilitates the diagnosis. Based on the analysis, it can be concluded that the name of Maria Fedorovna Deshchekina is associated with many innovations that later became traditional for Russian pediatrics.

RUDN Journal of Medicine. 2023;27(2):265-276
pages 265-276 views

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