Aim. To evaluate the level of staffing by general practitioners (GP) in medical organizations in Krasnodar Krai.

Materials and methods. Indicators characterizing the level of staffing by GPs in Krasnodar Krai hospitals were analysed using data from the state statistical observation form No. 30 “Information about a medical organization” for the 2009–2019 period. According to the data derived from the Krasnodar Krai Patient Register as of 01.01.2020, all GPs were divided into groups in terms of the ratio of the number of served population and the recommended values. Using the data of the Regional Register of Medical Workers as of 01.01.2020, the age composition of GPs was analysed.

Results. As of 01.01.2020, Krasnodar Krai featured 228 medical organizations subordinate to the Krasnodar Krai Ministry of Healthcare. Of these, 58 have full-time GP positions. The overall number of GP positions comprises 294, which are currently taken by 198 specialists (1.1% of the total number of doctors and 1.9% of doctors providing medical care on an outpatient basis). Over the studied period, stable indicators of the provision of the Krasnodar Krai population by GPs were noted; however, the level of staffing by GPs in hospitals was decreasing. This indicates a growing trend in the lack of GPs. An analysis of the actual load of 198 GPs showed that, on average, 1 GP serves 1219 people. For 26.8% of GPs, the number of served population increased the recommended values by 1.5 times or more. As a result, over 100,000 adults in the region are served under the conditions of excessive workload on GPs. The average age of GP is 50.1 ± 0.9 years. Currently, more than 25% of GPs are working retirees by age. In the medium term, this value may exceed 50%. Considering specialists who are about to retire, the estimated need for GPs is 146 doctors.

Conclusion. In order to provide affordable and high-quality primary health care to the population in Krasnodar Krai, the number of GPs should be increased. In addition, measures should be taken to raise the attractiveness of work in Krasnodar Krai hospitals.

Palliative care is aimed at enhancing the quality of life of patients living with life-threatening conditions and their families. According to the World Health Organization, about 40 million people require palliative care every year. Out of these people, 78% reside in low- and middle-income countries. 89% of children requiring palliative care are from low- and middle-income countries, with half of these children living on the African continent. Such a widespread prevalence and need for palliative care is expected to grow due to the increasing number of chronic non-communicable diseases, and the provision of palliative care at early stages reduces the frequency of unnecessary hospitalisations and the use of medical services.

Aim. To assess the structure and organisation of palliative care for children in Krasnodar Krai.

Material and methods. The study was conducted on the basis of medical institutions located in Krasnodar and other cities in Krasnodar Krai (Apsheron, Vyselkovsky, Gelendzhik, Kavkazsky, Kushchevsky districts, Leningradsky region, Seversky and Tuapse districts), which provide palliative care for children aged from 3 months to 18 years. Along with inpatient services, outpatient forms of palliative care for children, such as long-term artificial respiration for incurable patients, were analysed. Statistical methods of analysis were not used due to the descriptive character of the research.

Results. 28 palliative care beds for children were open in Krasnodar Krai over the period from 2013 to 2018. The number of visiting nurse brigades comprised 13. An analysis of the provision of palliative care in accordance with No. 985 form “Data on patients receiving palliative care” and the report of the palliative care structure as of September 1, 2018 showed that 193 children needed round-the-clock inpatient care. Out of these children, 71.5% and 21.2% suffered from CNS and cancer conditions, respectively, while 7.3% were referred to the ‘other diseases’ group. 250 patients were treated in the offices of palliative care, including 94.4% of neurological patients, 2.8% of cancer patients and 2.8% of children with other pathologies. At home, 14 incurable patients received long-term artificial respiration, 78.6% of whom were children with hereditary neuromuscular diseases, 7.1% with congenital malformations of the central nervous system, 7.1% with lysosomal storage disease and 7.2% with Pompe disease.

Conclusion. Palliative care is one of the priority branches of medicine in the Russian Federation. The problem of providing palliative care for children is of particular significance due to the growing number of patients with life-threatening and terminal conditions.

Aim. To compare the results of lower limb revascularization in patients with diffuse lesions of lower limb arteries who underwent femoral-distal bypass surgery and isolated reconstruction of the deep femoral artery (DFA) in the immediate postoperative period.

Materials and methods. The study included 86 patients with diffuse arterial lesions of lower extremities, 52 (60.4%) men and 34 (39.6%) women with the average age of 67.3 ± 16.8 years. All patients had diffuse lesions of the arteries below the Poupart’s ligament; the condition of the lower leg arteries was 5–8.5 points on the Rutherford scale. Trophic ulcers were present in all cases. Group 1 included 48 patients who underwent reconstruction of lower leg arteries. Group 2 included 38 patients whose surgical intervention was limited to endarterectomy from the common femoral and deep femoral arteries.

Results. In the early postoperative period, 1 (2.1%) patient (from group 1) died from developed myocardial infarction. The patient underwent a femoral-popliteal-tibial bypass surgery with a composite Y-shaped graft. In group 2, no fatal complications were observed. After the operation, all patients demonstrated an increase in the linear blood flow velocity in the arteries of the foot and the transcutaneous oxygen tension (TOT). The TOT level 14 days after surgery comprised 44.1 mm Hg and 39.9 mm Hg (p> 0.05) in groups 1 and 2, respectively.

Conclusions. In 86.8% of patients, isolated profundoplasty followed by vasotropic therapy allows the target values of TOT to be obtained, which is necessary for successful healing of lower limb trophic ulcers.

Aim. To evaluate and analyse features of abdominal delivery in maternal care institutions (level III) in Krasnodar Krai on the basis of M.S. Robson’ obstetric care criteria (2001) and indicators of cesarean section efficacy.

Materials and methods. A retrospective study of archives from two Krasnodar Krai obstetric institutions (level III) (the perinatal centres of the Children’s Regional Clinical Hospital and the Regional Clinical Hospital No. 2) was carried out. The material for analysis was the number of births, surgery activity and perinatal mortality indicators (2017).

Results. A comparative analysis of abdominal delivery in two leading perinatal centres of the Region revealed low levels of cesarean section efficacy. The monitoring of obstetric conditions, which had the greatest influence on the growth of abdominal delivery cases, was carried out using M.S. Robson’ system. It was revealed that the largest increase in abdominal delivery was observed in patients included in groups I and V.

Conclusion. Despite the fact that the efficacy of abdominal delivery in Krasnodar Krai maternal care institutions (level III) is low, a detailed individualised analysis of indications for the performed surgical labour revealed obstetric practices (uterine scars, fetal distress, anomalies in labour), which increased the level of surgical activity. However, taking into account the specificity of indications for hospitalisation of patients in these medical institutions (severe extragenital pathology, complicated pregnancy), an increase in operative activity and low effectiveness of cesarean section are justified.

Aim. To study the effect of mutations in the KRAS gene on the clinical course of intrahepatic cholangiocellular cancer (ICC) after surgical treatment in the Russian population.

Materials and methods. A molecular genetic study of tumour tissue samples from 33 patients with intrahepatic cholangiocellular cancer obtained after surgical treatment was carried out using real-time polymerase chain reaction.

Results. In the Russian population, the frequency of mutations in the KRAS gene in ICC was 27%, mainly in 12 (78%), 13 (33%), 61 (55%), 117 (44%) and 146 (44%) codons of 2, 3, 4 exons. In terms of KRAS gene mutations, intrahepatic cholangiocellular cancer is characterised by a pronounced heterogeneity. As a rule, the KRAS gene demonstrates multiple mutations at several loci and co-mutations in other genes, in particular, in IDH1/IDH2, PIK3CA, NRAS and BRAF genes. KRAS gene mutations in ICC were found to be significantly more common in women. The overall survival rate was significantly higher in patients with a KRAS mutation as compared to those with the wild type of the gene. Regarding the relapse-free survival rate in the groups of patients with the mutant and wild type of the KRAS gene, no significant differences were found.

Conclusion. In the Russian population, no negative association between mutations in the KRAS gene and clinical outcomes was observed.

Aim. To determine the frequency of structural damage to the pyramidal tract in the region of crus posterius capsulae internae in children with a birthweight of less than one and a half kilograms with perinatal hypoxic damage to the nervous system using the value of fractional anisotropy according to diffusion-tensor magnetic resonance imaging at 39 weeks of post-conceptual age (PCA).

Materials and methods. The study included 68 children born with a very low birthweight and 59 children with an extremely low birthweight demonstrating brain structural changes at 39 weeks of postconceptual age according to neurosonography. At 39 weeks of postconceptual age, the children included in the study underwent diffuse tensor magnetic resonance imaging (DT MRI) with the determination of fractional anisotropy.

Results. At 39 weeks of PCA, all children had impaired neurological status. During DT MRI, the area of interest was crus posterius capsulae internae. Significant differences in the nature of structural damage to the pyramidal tract in the area of interest between children born with a very low and extremely low birthweight were not observed.

Conclusion. Damage to the pyramidal tract was observed in 22.0% of children born with an extremely low birthweight, and in 13.2% of children born with a very low birthweight; partial destruction of the pathways was noted in 47.5% and 45.6% of children, respectively. Intact pyramidal tracts were visualized in 30.5% of children born with an extremely low birthweight and 41.2% of children born with a very low birhtweight.

Aim. To evaluate the clinical and immunological features of the early gestational period in patients with adenomyosis.

Materials and methods. The study included 110 patients with first spontaneous pregnancy in 6–9 weeks. 75 pregnant women with a history of grade 1 adenomyosis were divided into two groups: group 1 comprised 43 patients with a threatened miscarriage, group 2 included 32 patients without a threat of pregnancy termination. Group 3 (control) included 35 pregnant women without a burdened history with a physiological pregnancy course. The cytokine profile of peripheral blood and cervical mucus was studied, as well as the level of LL-37 (cathelicidin) antimicrobial peptide.

Results. A pro-inflammatory shift of the cytokine balance as well as increased pro-angiogenic activity, determined by the VEGF-R2 / VEGF-A ratio, were observed in pregnant women with grade 1 adenomyosis during a physiologically ongoing pregnancy in the 1st trimester. A threatened miscarriage in the presence of adenomyosis is accompanied by statistically significant changes in the cytokine profile, a decrease in pro-angiogenic activity and an increased level of LL-37 in cervical mucus.

Conclusion. Pregnancy with adenomyosis of the 1st degree, in the absence of other risk factors, is complicated by a threatened miscarriage in more than half of cases. The revealed clinical and immunological aspects of early reproductive losses require further in-depth study, since these signs may indicate the presence of chronic endometritis in patients with adenomyosis not determined by non-invasive research methods.

Aim. To carry out a quantitative immunophenotypic characterisation of cellular corporations in a mononuclear inflammatory myocardial infiltrate in the cell and humoral forms of heart transplant rejection using the computer morphometry of endomyocardial biopsy samples.

Materials and methods. Endomyocardial biopsy samples (n = 226) were obtained from 56 heart recipients who underwent transplantation in 2018–2019. Sections with a thickness of 5 μm after the paraffin infiltration were stained with hematoxylin and eosin according to the standard procedure. The expression of CD3 T-lymphocyte, CD20 B-lymphocyte and CD68 macrophage markers was determined by the immunohistochemical streptavidin-biotin method. Using computer morphometry, the staining area coefficient (SAC) was calculated as the percentage of the total area of the stained objects to the area of the biopsy. The statistical processing of the results included verification of the distribution nature by the Kolmogorov-Smirnov method and the calculation of the Cramer — Welch criterion.

Results. Lymphocytes and macrophages were found in the inflammatory infiltrate of all heart transplants. The expression of CD3 T-lymphocyte marker in the absence of rejection (0R) was at SAC = 0.99 ± 0.02%. In comparison with 0R cases, this coefficient increased 2.1 times (p <0.05), 3.4 times (p <0.05), 5.5 times (p <0.05) and 4.8 times (p <0.05) in 1R, 2R, 3R and humoral rejection, respectively. The expression of the CD20 B-lymphocyte marker in 0R cases was characterised by SAC = 0.19 ± 0.01%. In comparison with 0R cases, this coefficient increased 2.7 times (p <0.05), 3.4 times (p < 0.05), 4.4 times (p <0.05) and 9.5 times (p <0.05) in 1R, 2R, 3R and humoral rejection, respectively. The value of the CD68-positive macrophage region for 0R was only 0.34 ± 0.01%. This parameter increased 2.7 times (p <0.05), 4.0 times (p <0.05), 9.6 times (p <0.05) and 4.1 times (p <0.05) in 1R, 2R, 3R and humoral rejection, respectively.

Conclusion. Cellular corporations in the mononuclear inflammatory infiltrate of transplanted heart are characterised by the predominance of T-lymphocytes in the cases of both cellular and humoral rejection. The expression of the B-lymphocyte marker is most pronounced in an antibody-mediated form. The maximum presence of macrophages in the infiltrate characterises severe cell rejection. An increase in the severity of cell rejection leads to an increase in the relative content of B-lymphocytes and macrophages in the infiltrate.

Aim. To determine the frequency of liver pathologies among the causes of death from gastrointestinal diseases in Krasnodar Krai in 2014–2018.

Materials and methods. The prevalence of liver pathologies in the structure of deaths from gastrointestinal diseases was studied according to the annual reports of the Bureau of Forensic Medical Examination of the Ministry of Health of Krasnodar Krai (FME Bureau), medical certificates of death (form No. 106/U-08) issued by forensic experts and registered in the mortality monitoring database (Parus information system), and data obtained from the Medical Information Analytical Centre of Krasnodar Krai for 2014-2018.

Results. Liver pathologies account for more than 50% cases in the structure of mortality from gastrointestinal diseases. More frequently, this reason caused death in 50–60 year old men and 60–65 year old women. Liver pathologies were found mainly in urban residents. It is noteworthy that, in the studied period, such deaths most frequently occurred at home, on the street, in public transport, etc.; only about 15% of patients died in hospitals. Among the registered liver diseases leading to death (ICD 10, headings K70–K77), cirrhosis of various etiologies was the leading cause, with “unspecified cirrhosis” being ranked the first place. Over the studied period, this cause of death showed a growing trend. Thus, 67.12%, 74.59%, 89.58% and 85.12% of such cases were registered in 2015, 2016, 2017 and 2018, respectively. In 2014–2016, cirrhosis and liver fibrosis (code K74), and alcoholic cirrhosis (code K70.3) were ranked the 2nd and 3rd more frequent death cause, respectively. Since 2017, alcoholic cirrhosis of the liver has occupied the 2nd place. However, over the 2014–2018 period, a decrease in the frequency of cirrhosis of alcoholic etiology was noted: its share was 10.52% of all cirrhosis in 2015, decreasing to 10.17%, 6.59%, 4.86% and 4.39% in 2015, 2016, 2017 and 2018, respectively.

Conclusion. Although mortality due to gastrointestinal diseases continues to decrease, liver pathologies remain to be the leading cause in 50% of such deaths. The leading disease is cirrhosis and unspecified liver fibrosis. According to the FME Bureau, deaths from cirrhosis occur outside hospitals in more than 85% of cases. The absence of cirrhosis verification by the etiological factor during autopsy requires the development of an algorithm of action, which should include a full-fledged investigation of the corpse, subsequent histological examination, assessment of pathomorphological signs taking into account clinical and medical history data and exclusion of the viral process by conducting serological tests.

Interdisciplinary publications suggesting an etiopathogenetic relationship between sensorineural hearing loss and some chronic non-communicable diseases were reviewed. A substantial amount of data on atherogenesis, thrombosis and immunological processes affecting the blood circulation of inner ear receptor cells has so far been accumulated. Various reasons for sensorineural hearing loss have been studied, such as changes in the rheological properties of blood; arteriole hypertonicity; precapillar sphincter dysfunction; impaired lipid metabolism leading to the lack of tissue oxygenation and dystrophy and necrosis of the organ of Corti. The definition of endothelial dysfunction has been given. The role of vasomotor, thrombophilic, adhesive and angiogenic forms of endothelial dysfunction in the development and progression of sensorineural hearing loss under the influence of harmful work-related factors, with arterial hypertension, coronary heart disease, diabetes mellitus with the most common and aggressive disorders of the microvasculature has been determined. A clear relationship between the development of sensorineural hearing loss in diabetic microangiopathy has been established. Historical data on the study of the mechanisms of sensorineural hearing loss were analyzed. The aim of this article was to conduct a literature review of interdisciplinary publications with a particular focus on the role of sensorineural hearing loss in the working population in predicting endothelial dysfunction in some chronic non-communicable diseases. The novelty of this article consists in the consideration of occupational and population risk factors for chronic non-communicable diseases in the form of their cascade, which also leads to sensorineural hearing loss.

Aim. To describe a case of fat obliteration using platelet-rich plasma in a patient with recurrent chronic frontal sinusitis.

Materials and methods. A clinical case of a 60-year-old patient who had repeatedly performed extranasal frontotomy for recurrent chronic frontal sinusitis with a short-term effect is described. Due to the ineffectiveness of conservative and traditional surgical treatment, taking into account the characteristics of the clinical picture and the presence of a cosmetic defect in the area of projection of the right frontal sinus, as well as CT results (postoperative bone defect of the right half of the frontal bone), a right-side extranasal frontotomy was performed. The operation involved sinus obliteration with adipose tissue obtained from areas of the thigh anterior surface by lipoaspiration under low pressures with the addition of platelet-rich plasma (PRP) prepared by a single centrifugation of whole venous blood. An assessment of the patient’s condition and fat transplant was carried out on the basis of objective examination after 4 and 6 months and 1.5 year after the surgery and the results of control computed tomography (CT).

Results. No complaints regarding nasal breathing from the frontal sinus were registered during control examinations. A good cosmetic result and the absence of pain during palpation in the right frontal sinus were observed. According to CT results, the density of the contents of the frontal sinus corresponded to that of adipose tissue; the volume of material did not changed.

Conclusion. Frontal sinus obliteration with adipose tissue and PRP addition is a promising method for treating patients with recurrent chronic frontal sinusitis and repeatedly performed extranasal frontotomy. This method has several advantages over other methods.

Aim. To describe a clinical case of carotid chemodectoma in a patient seeking treatment from an otorhinolaryngologist.

Results. A 79-year-old woman complained of sore throat and difficulty swallowing. Mesopharyngoscopy revealed a significant asymmetry of the pharynx on the right with a sagging soft palate. Computed tomography revealed the asymmetry of the pharynx on the right due to compression from outside. An irregularly shaped formation intensely accumulating contrast medium was detected in the periopharyngeal space on the right, near the bifurcation of the carotid artery. Carotid chemodectoma was suspected. The patient underwent surgical removal of the chemodectoma followed by the autoarterial reconstruction of the carotid artery on the right. The postoperative period was uneventful.

Conclusion. The management of patients with carotid chemodectoma requires an interdisciplinary approach with participation of vascular surgeons, otorhinolaryngologists and radiologists. This approach ensures timely surgical treatment leading to complete recovery without neurological consequences and profuse blood loss. The disease can be mistaken for a peritonsillar abscess with the possibility of serious complications during surgical treatment.

This article describes a clinical case of lepromatous leprosy. Despite the sporadic incidence of leprosy in Russia, the presented clinical observation demonstrates that clinicians must maintain vigilance with regard to leprosy. Close attention and in-depth study of the history of the disease is required both in endemic and (in view of active migration and tourist flows) non-endemic regions, since timely diagnosis of this mycobacteriosis can present significant difficulties.