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general condition and the nature and methods of fracture surgery.
On all patients were performed laboratory and instrumental clinical study determined the level of calcium, phosphorus, hydroxyvitamin 25(OH)D, alkaline phosphatase, parathyroid hormone (PTH) and osteocalcin.
To determine BMD ultrasonic densitometry was performed in three standard parts of the skeleton (lumbar, proximal femur, forearm). Were estimated bone mineral density L1-L4 spine, proximal femur and distal forearm. BMD assessment was performed according to WHO recommendations Z- and T-criteria. In women during menopause and men over 50 years using T-test data in accordance with the interpretation of densitometric WHO classification (rate from 2.5 to 1, osteopenia from —1 to —2.5, osteoporosis from —2.5 SD and below).
Results and discussion. In people with diabetes type 2 breach phosphorus-calcium balance may be at different stages of the disease, and many researchers indicate normal or slightly reduced levels of calcium and phosphorus in the blood of patients, which coincides with our data. In the experimental group levels of calcium was 2.13 ± ± 0.03 mmol/l, and phosphorus — 1.05 ± 0.04 mmol/l. In the control group levels of calcium was 2.37 ± 0.03 mmol/l, and phosphorus — 1.28 ± 0.04 mmol/l. The same applies to hydroxyvitamin 25(OH)D, the level of which was in the normal range in both groups. Alkaline phosphates' level in experimental group was 128.70 ± 0.04 IU/l, in the control group — 156.30 ± 0.04 IU/l.
Important role in the regulation of bone formation and osteoreparation pay parathyroid hormone. In the
experimental group was marked higher levels of parathyroid hormone than in the control group, and was 58.08 ± 2.70 pg/ml and 41.55 ± 1.90 pg/ml, respectively.
Nowadays it is admitted that the most informative indicator of bone growth is the level of osteocalcin, which is synthesized by osteoblasts. In patients with type 2 diabetes osteocalcin level was 19.92 ± 0.80 ng/ml, in control group — 32.87 ± 0.90 ng/ml.
In the study of data of densitometry in three locations (lumbar, proximal femur, forearm) reduction in bone mass (T < —1) detected in most patients, with those in the experimental group it was more pronounced than in the control group. In the experimental group prevailed patients with a diagnosis of osteoporosis (T < —2.5) in the control group prevailed patients with osteopenia.
When comparing the densitometric measurements in three standard points were observed that in the experimental group osteopenic syndrome most often seen in the proximal femur (78.9 %), whereas in the control group were most pronounced changes in the lumbar spine (73.9 %).
Conclusion. The severity and duration of type 2 diabetes affect the bone metabolism and cause leakage oste-oreparation in patients with fractures of the trochanteric area of the femur through changes in mineral and hormone balance.
The possibility of less reversible changes in bone tissue on a background of type 2 diabetes poses the need to address the issue of early diagnosis and treatment of abuse of bone metabolism in this group of patients.
SOLYEYKO O., STEPANIUKO., STEPANIUK T., KOROBKO O. Vinnytsia National Medical University named after N.I. Pyrogov, Vinnytsia, Ukraine
The Influence of Sartants on the Gout Course
Introduction. Modern science considers the level of uric acid as a risk factor for cardiovascular pathology. Hyperuricemia is the basis for the gout development. The doubled increase in number of diagnosed gout cases and related complications in the last decade requires finding new aspects of pathogenesis and treatment approaches. Today, the largest percentage of use as antihypertensive agents in the world belongs to sartans group. Special place among numerous of sartans pleiotropic properties belongs to urico-zuric effect of this group of drugs. Multicenter trials that investigated the influence of sartans on the course of arterial hypertension, only stated their influence on the level of uric acid in the blood. But, there is no evidence of sartans influence on the gout course.
Aim. To study the influence of sartans on the gout course.
Materials and methods. During the years of 20132014, we have examined 63 of male patients suffered from gout. Patients were randomized into two groups: the first consisted of patients (30 people) who took convention-
al treatment of gout, the second one (33 people) — those, who took sartans as a part of comprehensive treatment of this disease. The average duration of sartans use for group II of patients was 8.3 ± 0.7 months. Both groups were representative by age, level of uric acid, hyperlipidemia before the treatment, the level of process activity, the number of patients with burdened family heredity. The average age of patients in the first group was 43.4 ± 1.5 years, and group II — 45.6 ± 1.3 years. Uric acid levels before treatment were: 0.53 ± 0.11 mmol/l, 0.54 ± 0.10 mmol/l, respectively, in groups I and II. Hyperlipidemia was determined with 56.6 % of patients in group I and 54.56 % — group II. Process activity of II degree (42.4 and 43.4 %, respectively) was observed in most patients of groups I and II. The percentage of patients with burdened family heredity in group I was 13.3 %, in II — 21.2 %.
Results. Analysis of anamnestic and clinical and instrumental features revealed that the most patients of group I (46.7 %) the beginning of the disease covered live period from 40 to 50 years, the start period of the disease for most patients of group II (45.5 %) covered live time from 50 to 60 years. Group I had big number of patients with disease experience from 5 to 10 years (56.6 %), in group II dominated the percentage of patients with disease experience from 2 to 4 years (54.5 %). Patients were divided under number of injured joints as follows: monoarthritis of traditional localiza-
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tion was observed in 10 % of patients in group I and 24.3 % of patients in group II. Injury of 8—10 joints, however, prevailed in group I of patients (36.7 % of patients) compare to group II (27.3 %). 30 % of patients in group I showed commitment to constant treatment and 65 % — group II. At the same time, the treatment only during disease aggravation support 60 % of patients in group I and 25 % — group II. In both groups, most patients had II degree of radial process (60 and 54.5 %, respectively). But 66.6% of patients in group II had I degree of joints dysfunction, whereas II degree dysfunction dominated in group I (63.4 %). Except articular dysfunctions, tophi dominated in patients of group I (23.3 % of patients), while groups I and II did not differ in percent of diagnosed gouty kidney (10 and 9.1 %, respectively). Among accom-
UGLYAR T., ZHULKEVYCH I., NEDOSHITKO V. Ternopil State Medical University named after I.Ya. Gorbachevsky, Ternopil, Ukraine
Aseptic Necrosis of the Femoral Head as a Possible Consequence of Hodgkin Lymphoma Chemotherapy
Introduction. Four adult patients with malignant Hodg-kin's lymphoma were treated with combination chemotherapy including an alkylating agent and intermittent high-dose prednisone (in two cases). Twelve to 24 months after initiation of therapy, osteonecrosis of the femoral head developed. This was unilateral in all cases, and presumably didn't represent a complication of steroid administration, as two of the patients received 4 and 6 month of corticosteroids therapy. Necrosis of bone may be a low-frequency long-term complication of combination chemotherapy in lymphoma.
Administration of corticosteroids is known to be associated with the development of osteonecrosis, or avascular necrosis of bone, particularly of the femoral and humeral heads. In the main, this occurs in patients receiving doses in excess of physiologic replacement for prolonged periods of time. In recent years, increasing numbers of patients with malignant Hodgkin's lymphoma have been treated intermittently with combinations of chemotherapeutic agents, including corticosteroids.
Materials and methods. From 2009 through 2014, 283 patients were treated with chemotherapeutic regimens involving a combination of drugs for advanced Hodgkin's disease. Virtually all the patients were adults. The treatment programs consisted of intermittent administration of such schemes of chemotherapy as ABVD and BEACOPP. Drug dosages and scheduling have been described in detail elsewhere, but the BEACOPP combination includes the administration of 2 weeks of daily oral prednisone, 40 mg/m2 body surface area for 4—6 month. All charts of these lymphoma patients in whom a diagnosis of aseptic or avascular necrosis of bone had been recorded (two patients both ABVD and BEACOPP) were reviewed for this report. In all instances the bone abnormality involved the femoral head and developed after initiation of chemotherapy. The diagnoses were made by radiographic means, using standard criteria, and operative intervention has been required and performed in all these patients.
panying pathology in patients of both groups hypertension (63.3 and 42.4 %) and obesity (77.3 and 60.6 %) dominated. Hyperinsulinemia and diabetes significantly predominated in group I of patients, which correlated with a greater percentage of tophi in the same group.
While treatment the required level of uric acid 0.38 ± ± 0.01 mmol/l was gotten only in patients of group II, whereas uric acid was 0.46 ± 0.01 mmol/l in patients of group I.
Conclusion. Hereby long-term use of sartans in patients with gout leads not only to sustained reduction of uric acid contain in the blood serum, but also to improvement in the course of articular syndrome and reduction of the severity extraarticular dysfunctions and comorbidity percent.
Results. We wish to report the appearance of osteonecrosis in four such patients, two of whom were given 4 to 6 month of intermittent steroid therapy. These four cases of osteonecrosis arising after combination chemotherapy for lymphoma represent 1.4 % of all our patients so treated. The time from initiation of corticosteroid (and additional cytotoxic) therapy to radiographic diagnosis of osteonecro-sis was 12 and 16 months in the two patients in whom intermittent steroids were given. The other two patients, who hadn't received intermittent steroids, in 12 and 24 months abnormal roentgenogram occurred. This was unilateral in all cases. All but one were male, despite an approximately unitary sex ratio in our patient population. The symptoms of hip and lower extremity pain were typical, the surgical intervention was considered and performed in all four patients.
Conclusion and discussion. Several theories have been proposed to account for an increased incidence of os-teonecrosis after combined chemotherapy administration. Vascular obstruction by fatty emboli in areas of bone with poor collateral circulation is a mechanism that is often discussed, and both clinical and experimental supporting evidence have been described. These findings have not been confirmed by others, however; microtrauma in osteoporotic bone, possibly exacerbated by diminished sensibility from the antiinflammatory effects of steroids is among other suggested etiologic factors. Avascular necrosis of bone has complicated the treatment of a variety of diseases, including many in which this lesion is not part of the natural history of the disease. To our knowledge, osteonecrosis has previously been reported in the course of intermittent corticosteroid therapy of lymphoma, as well as in untreated lymphoma among the conditions associated with development of avascular necrosis of the femoral head. Steroids were administered to two of our patients for relatively long periods of time. In some reviews of the problem of aseptic necrosis complicating steroid therapy, the time from initiation of treatment to development of necrosis is stated to vary from 6 to 54 months. Daily prednisone dosage in most patients was 10—90 mg. Such articles point out that total steroid dose, daily dose, and duration of drug administration associated with osteonecrosis may be minimal. The possibility that our patients suffered from idiopathic necrosis of the femoral head should also
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