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Issue. Articles

1(8) // 2012

 

 

1. Editorial

 

International standards of management of patients with MDR TB: review of current who guidelines

Yu.I. Feshchenko, S.O. Cherenko

Current Guidelines for the management of drug resistant tuberculosis were analyzed in a historical perspective from 1996 to 2011. Emphasis is placed on the interpretation of the new 2011 edition of the Guidelines, due to preparing the changes in legal acts of Ukraine, according new WHO recommendations.  

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2. LECTURES

 

Tuberculosis diagnosis: past and present In honour of the 130 anniversary of Robert Kochs discovery of the causative agent for tuberculosis

V.I. Petrenko

Exact and rapid diagnosis of tuberculosis is of primary importance in establishing appropriate clinical and infection control management. Although there have been significant advances in diagnostic technologies for tuberculosis during the past decade, most countries around the world are still using the same microscopy examination of sputum that was used over hundred years ago. However the lack of accurate diagnosis leads to an unacceptable burden of the problem and to a waste of precious resources in poor countries. Thus recent summary on diagnostic methods is of great importance in order to provide progress in the fight against tuberculosis.

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3. Lectures

 

The organ electrophoresis in complex treatment of the destructive pulmonary tuberculosis

B.V. Noreiko, S.B. Noreiko, Yu.A. Gryshun

The practical and scientific aspects of organ electrophoresis application in complex treatment of the tuberculosis are presented in the lecture. 1346 TB patients were treated with courses of organ electrophoresis for the last three years (2008—2010) in Donetsk Regional Clinical Tuberculosis Hospital. The results of treatment among 489 patients with primary diagnosed pulmonary destructive tuberculosis were studied. Sputum conversion was revealed in 80 % patients, who received the complex chemotherapy in combination with organ electrophoresis, whereas of control group patients showed only 43 % sputum conversion.

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4. ORIGINAL RESEARCH

 

Possibility of correction of some changes of glutathione-dependent enzymes activity in the combined experimental pathology

V.. Zhadan

Objective: to study the activity of glutathione-dependent enzymes in experimental infectious pneumonias associated with chronic alcohol intoxication and the possibility of its correction with the use of omega-3 polyunsaturated fatty acids (PUFAs).

Materials and methods. The study was conducted on 70 white mongrel male rats. Infectious pneumonia and chronic alcoholic intoxication were chosen to be the models of experimental pathology. The study object was cytosolic fraction of liver after microsomes selection. State of glutathione-dependent enzyme system was studied by activity of glutathione-peroxidase (AGP), glutathione-reductase (GR), glutathione-transferase (GT).

Results and discussion. We studied and evaluated liver glutathione-dependent system indices in experimental infectious pneumonia and infectious pneumonia associated with chronic alcohol intoxication and the effect of omega-3 PUFAs on these exogenous enzymes. A number of changes in the activity of these enzymes was revealed: both infectious pneumonia and chronic alcohol intoxication were followed by significant increase in activity of GP, and in combined experimental pathology not only significant increase in the activity of GP, but aso significant increase in activity GT were revealed. All that may indicate a strengthening of the processes of detoxification in the liver. Marked normalizing and correcting effect of exogenous omega-3 fatty acids on the activity of glutathione-dependent enzymes were stated to be in these pathologies.

Conclusions. Experimental infectious pneumonia associated with chronic alcohol intoxication leads to disruption of homeostasis in the glutathione-dependent enzyme system. In these experimental pathologies the influence of omega-3 fatty acids due of connection of regulatory mechanisms leads to compensatory-adaptive response, aimed at normalizing the catalytic properties of glutathione-dependent enzymes.

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5. Original research

 

Lung tuberculomas: clinical and anatomic characteristics in epidemic period

I.V. Liskina

Objective: to specify some pathological characteristics of lung tuberculomas and surgical approaches for its treatment.

Materials and methods. All surgical intervention cases due to lung tuberculomas were analyzed for the period from 2001 to 2010. The material of investigation included case data, results of laboratory and histological examination of 317 patients. Sputum microscopy was performed for all patients and in some cases surgery material was also analized. In case of revealing MBT in sputum and/or operational material by cultural method drug susceptibility test was made. 345 microbiological examinations were performed.

Results and discussion. The localization of lung tuberculomas was specified: in majority of cases (63.4 %) it was revealed in upper lobes. The types of surgical interventions were studied; the main types of tuberculomas according to M.M. Averbach classification and the degree of specific inflammation for the moment of tuberculoma removing due to histological examination were established. The number of cases (46 cases, 14.5 %) with presence of sifting focuses in other lung lobes and/or tuberculosis lesions of another anatomic structures of thorax according to the clinical, radiological and/or morphological data was established. 

Conclusion. The localization of tuberculomas taking into account its prevalence is constant characteristic, without obvious tendency to changes in epidemic period comparing to ex-epidemic period. The number of cases of multiple tuberculomas has essentially raised in epidemic period. At present the main types of operations in patients with lung tuberculomas are segmental resection, multi-segmental resection and lobectomy. Among different anatomical types of tuberculomas the homogenic tuberculoma-caseomas prevail. At the moment of surgery in lung tissue the moderate activity of specific inflammation process is determined more frequently. the revealing of sifting focuses in other lung lobes On background of lung tuberculomas, the presence of accompanying tuberculous lesion of bronchus, peripheral lymphatic nodules and pleura is the evidence of tuberculosis progression.

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6. ORIGINAL RESEARCH

 

Pharmacotherapy of endothelial dysfunction in patients with HIV-infection/AIDS

S.R. Melenko, Yu.M. Lesiuk

Lately the special attention of scientists attracts the role of endothelium in HIV-infection pathogenesis. Endothelium provides an exchange between blood and tissues, homoeostasis of vascular wall and is an important barrier on the way of infection. Endothelium activation and damage produces molecules, such as a thrombomodulin, -selectin and von Willebrand factor, evaluating those markers allows to estimate the state of endothelia at different inflammatory processes. 

Objective: content of markers of endothelial dysfunction in blood of HIV-infected patients and its changes depending on the clinical stage of disease and different methods of treatment.

Materials and methods. 127 patients with HIV-infection/AIDS in different stage of disease were examined.

Results and discussion. The substantial growth of thrombomodulin, -selectin and von Willebrand factor contents was revealed in HIV-infected patients, and certain grows of mentioned indexes is observed in the immunodeficiency progression. Dipiridamol usage along with 3-month first-line antiretroviral therapy provided only partial retrogression of thrombomodulin, -selectin and von Willebrand factor indices. However, including dipiridamol in antiretroviral therapy normalizes the level of thrombomodulin and von Willebrand factor at the II clinical stage of HIV-infection, and provides certain retrogression at III—IV stages. The same substantial difference is set for -selectin index.

Conclusions. HIV-induced vascular wall lesion is specific for patients with HIV-infection/AIDS. Three months of symptomatic therapy does not influence on the state of endothelium, however, including dipiridamol in antiretroviral therapy maximally optimizes its state.

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7. Original research

 

Diagnostic importance of biochemical parameters of cerebrospinal fluid and level of immune suppression in HIV-infected patients with tuberculosis of the meninges and central nervous system

M.N. Gryshyn, S.V. Shyian, O.B. Tymchenko, E.S. Ablaieva

Objective. Identification of diagnostic and prognostic value of biochemical parameters of the CSF and the level of immunosuppression in HIV-infected patients with tuberculosis of the meninges and central nervous system.

Materials and methods. We examined 105 HIV-infected patients with tuberculosis of the meninges and central nervous system.

Results and discussion. The study revealed an inverse correlation between the level of CD4-lymphocytes, and cerebrospinal fluid protein levels. high level of correlation coefficient and a direct correlation between the level of CD4-lymphocytes and the concentration of glucose was recorded. Also a high level of correlation coefficient and a direct correlation between the level of CD4-lymphocytes and the amount of chloride in the cerebrospinal fluid were revealed. The inverse correlation between the level of protein and CSF glucose and chloride concentrations (r = –0.779), direct correlation between glucose and chloride level in liquor were discovered.

Conclusions. The revealed dependence has some prognostic value. The lower the number of CD4-lymphocytes, glucose and chloride is, and the higher protein index in CSF is, the more favorable clinical prognosis in HIV-infected patients with tuberculosis of the meninges and central nervous system is. Marked deviation from the normal level of an indicator of the CSF is a predictor of deterioration in other indicators and an indirect marker of adverse clinical course.

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8. ORIGINAL RESEARCH

 

Features of HIV-associated tuberculosis distribution in the Irkutsk region

.N. Novickaia, .P. Filipova, V.V. Havrylenko, .V. Zahorskaia, .V. Solovkov

The increase of amount of patients with the late stages of HIV-infection and worsening of clinical structure of HIV-associated tuberculosis predetermine severe requirement in the further study of all aspects of HIV/TB-coinfection, especially in regions with a high level of tuberculosis and HIV-infection, such as the Irkutsk region.

Objective: to learn epidemiology situation on tuberculosis, HIV-infection and HIV-associated tuberculosis in the Irkutsk region.

Materials and methods: statistical data of the Irkutsk regional antituberculous dispensary for period 1991—2010 and epidemiology indexes for Russian Federation.

Results and discussions. The study revealed that regional tuberculosis morbidity has increased almost 4 times for last 20 years and does not have downward trend. The prevalence and mortality increased 1.5 and 4 times respectively and continue to grow, that in general allows to consider tuberculosis epidemiology situation in this region to be unfavorable. Interference of two epidemics is verified by the unidirectional morbidity dynamics of tuberculosis and HIV-infection and high correlation dependence (r = +0.65). HIV/TB-coinfection morbidity increased 8.7 times during 2001—2010 years, that significantly exceeds an analogical index for Russian Federation. Proportion of hospital patient with HIV/TB coinfection was maximal in 2010 and made 32.6 % of all hospital patients, thus almost 1/3 of these patients had CNS lesion. The study revealed an increase of regional coinfection death rate, that grew 15 times for the last 6 years and made 37.2 % of general death rate of patients with tuberculosis for this year. CNS tuberculosis (70.7 %) leads among reasons of death of HIV-infected patients, less common are herpetic (13.2 %), cryptococcal (4.7 %), candidal (3.2 %) meningitis, cerebral toxoplasmosis (2.3 %) and CNS lesion of unspecified etiology.

Conclusions. Tense epidemiology situation concerning tuberculosis in the Irkutsk region is mostly due to influence of HIV-infection epidemic: cumulation of patients with the late stages of HIV-infection, worsening of clinical structure of thoracic and extrathoracic HIV-associated tuberculosis, proportion growth of HIV-associated tuberculosis of CNS. Thus, a study of clinical features, diagnostics and treatment of HIV-associated tuberculosis of CNS is one of the most actual phthisiology aims.

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9. Original research

 

Pathoanatomical features of tuberculosis in children who died in general pediatric departments

P.V. Kuzyk, I.I. Hoshowska, V.O. Kitov

Currently tuberculosis is among the ten most widespread reasons of child death. Child tuberculosis morbidity increased 2 times in the period of epidemic in Ukraine. Very important problem is significant amount of unrevealed tuberculosis cases among children that requires further study of epidemiology indexes, reasons of death rate and pathomorphism of child tuberculosis. 

Objective: to identify pathomorphological features of child tuberculosis using analysis of autopsy of children who died in general pediatric departments.

Materials and methods. Patient case history data and autopsy data for 11 children who died in general pediatric departments during 13 years (1999—2011) were analyzed.

Results and discussion. Primary pulmonary tuberculosis was found in 10 children, primary tuberculosis of small intestine — in one. Character of pathomorphological changes of internal organs, complications of tuberculosis, underlying and concomitant diseases and level of clinical diagnostics were determined. Mixed form of progress of tuberculous process was revealed in 9 (81.9 %) cases. In 3 (30 %) cases progress of primary tuberculosis resulted in the specific lesions of intestines. In 6 (54.5 %) cases tuberculous process itself resulted in death. In other 5 (45.5 %) cases other associated (four cases) and competitive (one case) diseases were revealed to significantly influence on thanatogenesis. Tuberculosis was clinically diagnosed in general pediatric departments in 3 (27.3 %) children, suspected — in 2 (18.2 %), not diagnosed — in 6 (54.5 %).

Conclusions. Modes of dying of children were tuberculous meningitis and multiply organ failure. All children had progress of primary tuberculosis. Tuberculosis was not diagnosed in general pediatric department in 54.5 % cases.

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10. ORIGINAL RESEARCH

 

Features of collagen formation in tuberculosis patients depending on the state of connecting tissue

L.A. Sukhanova

Objective: to study the features of collagen formation in tuberculosis patients depending on the connecting tissue state — with a presence or absence of connective tissue dysplasia (CTD).

Materials and methods. 47 patients with the new-onset pulmonary tuberculosis after surgery due to ineffective treatment were enrolled and CTD phenes (phenotypic characters) were studied. 36 patients with the presence of CTD phenes made up basic group, 11 persons without CTD phenes were comparison group. 

Results and discussion. The study revealed that optical density of various collagen types immunofluaescence depends on inflammation degree. Increase of inflammation activity is followed by decrease of collagen formation, especially at CTD.

Conclusions. Collagen formation disorder was revealed, that indicates significant decline of reparative processes in patients with the presence of CTD phenes.

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11. ORIGINAL RESEARCH

 

Blood oxygen saturation at various pulmonary diseases

I.T. Piatnochka, S.I. Kornaha, N.V. Tkhoryk

Objective: to study levels of arterial blood oxygen saturation in patients with new-onset tuberculosis, sarcoidosis, pleurisy, pneumonia and lung cancer, followed by pathogenetic therapy correction.

Materials and methods. The study involved 418 patients, who were examined with the use of clinical, radiological, laboratory and functional methods. Determination of the degree of arterial blood oxygen saturation was provided by pulseoximeter «Yutasoksy-201».

Results and discussion. Saturation of blood in (96.35 ± 0.28) % patients with new-onset tuberculosis, (95.44 ± 0.31) % patient with sarcoidosis, (94.20 ± 0.21) % patients with pleurisy, (93.73 ± 0.16) % patients with pneumonia and (91.93 ± 0.83) % patients with lung cancer is reduced in comparison with healthy individuals (98.35 ± 0.31) %). The degree of saturation of arterial blood oxygen depends on the specific disease due to certain pathomorphological and pathophysiological features.

Conclusions. The degree of saturation of arterial blood oxygen varies at different lung diseases due to specific to each disease certain pathomorphological and pathophysiological processes. This should be considered during pathogenetic therapy and determining prognosis.

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12. PRACTICE AND EXPERIENCE

 

Experience of sanatorium rehabilitation of children from the high risk groups at the Transcarpathian local submission sanatorium Choven

V.V. Skryp, E.P. Shymko

The work presents analyzis of the selection and diagnostics features and results of the sanatorium rehabilitation of 3678 children, who have been treated at the local submission sanatorium for the last five years.

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13. PRACTICE AND EXPERIENCE

 

MTB infection in children: prophylactic treatment in sanatorium of the Sumy region

V.Ya. Pustovit, .B. Avramets, L.V. Varenik, V.I. Leonov, T.B. Makavoz

The paper analyzes the structure of MTB infected children who underwent treatment in the Shostka region child tuberculosis sanatorium in 2010. Main risk factors for infection and disease establishment for that group of children were identified. Results of the preventive treatment in the sanatoriums were described.

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14. MEDICINES

 

Efficacy of treatment with Enercel for new-onset, presumed drug-sensitive and confirmed multidrug resistant pulmonary tuberculosis

V. Dubrov, T. Dubrova, V. Suhareva, D. Christner, J. Baiamonte, D. Laurent

Objective: to determine efficacy of the complex homeopathic medicine Enercel in short-term treatment of new-onset, presumed drug-sensitive and confirmed multidrug resistant (MDR-TB) pulmonary tuberculosis (TB).

Materials and methods. Six new-onset, presumed drug-sensitive pulmonary TB and seven MDR-TB patients were enrolled. They each had baseline AFB-positive sputum smears. Patients were treated with Enercel by intravenous, aerosolized, sublingual and intranasal routes for 30 consecutive days. Endpoints included chest X ray, sputum AFB smears and Quality of Life (QOL) evaluation. The last was assessed by cough, energy, mood, appetite, night sweats, weight and ease of breathing. Safety of Enercel was evaluated by complete blood count and liver function testing.

Results and discussion. Six (100 %) presumed drug-sensitive patients were sputum AFB smear negative after 30 days. These patients had also significantly decreased infiltrates and cavitations by chest X ray. QOL significantly improved in all 6 patients. Two of seven (28 %) MDR-TB patients were AFB smear negative and 1 more (14 %) had significantly less AFB-positive organisms after 30 days. Each of these 3 responders had significantly improved hest X ray findings. QOL significantly improved in each of the 7 patients. There were no toxicity or side effects associated with Enercel use.

Conclusions. Enercel was highly effective in a short time (30 days) for new-onset, presumed drug-sensitive pulmonary TB and confirmed MDR-TB patients. There were no adverse events associated with Enercel administration. Enercel may be useful in improving outcomes, limiting mortality, improving general health, and reducing length of treatment in these populations. Finally, long-term medical costs to public health systems may be significantly reduced.  

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15. CLINICAL CASE

 

Case study: successful treatment of cryptococcal meningoencephalitis in HIV-infected child

O.. Zalata, N.V. Rymarenko, A.E. Chytakova, E.R. Mazynova, H.L. Kyselova, E.V. Zdyrko

The article shows the case of cryptococcal meningoencephalitis in 12 years-old HIV-infected child taken from own clinical experience.

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16. EPIDEMIC SITUATION

 

Topical issue on diagnosing and treatment of tuberculosis patientsin the Kherson region during 20062010 years

V.M. Buriatinskyi, H.V. Koval, T.M. Lenchevska, O.M. Panchenko

The analysis of the results of treatment of patients with new-onset tuberculosis was carried out considering timeliness of case detection, treatment compliance, drug resistance development and HIV-TB coinfection.

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17. Reviews

 

Tuberculosis of the skin: clinical manifestations, diagnosis, differential diagnosis

E.N. Raznatovskaia, Yu.M. Bobrovnichaia-Dvizova, A.V. Dvizov, T.S. Fedchenko

The article presents the clinical manifestations, diagnosis and differential diagnosis of major clinical forms of tuberculosis of the skin.

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18. Reviews

 

Tuberculosis in the correctional facilities of the penitentiary system

S.V. Zaikov, O.V. Plikanchuk

The prevalence of tuberculosis in the correctional facilities of the penitentiary system exceeds analogical in civil society in 10—100 times. The peculiarity of tuberculosis epidemic in prisons is its frequent combination with HIV-infection and multidrug resistance of the disease agent. Medical service in the penitentiary system must be based on the close collaboration with local or national health service. An unlimited access to timely diagnostics, controlled and continuous treatment of tuberculosis must be provided for every prisoner. The increase of antituberculous measures efficiency in the correctional facilities of the penitentiary system will promote the improvement of situation with tuberculosis in civil society.

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19. Reviews

 

Modern opinions at antiretroviral therapy in patients with the tuberulosis/HIV c-infection

O.V. Korzh

There is the review of literature for the last few years in the article. Analysis of  modern data in relation of antiretroviral therapy (ART) in c-infected TB/HIV patients are represented. The researches opinions on such definition as Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome, ART-Associated Tuberculosis, the Unmasked Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome are presented. It is underlined, that these definitions are not final and still need confirmation in clinical practice. Data about immune mechanisms that are in the basis of these phenomena are analyzed. It is shown, that at development of Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome not only lungs but internal organs can be also involved in the tuberculous process. Many attention are given to existent data about advantage and disadvantage for early starting ART in patients with  TB/HIV c-infection, it is shown, that the timing of ART beginning is determined by the state of the immune system. Data about efficiency of prednisone in correction of Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome are discussed. Conclusion about expedience of subsequent scientific researches in the given direction is done. 

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