Vol 31, No 1 (2025)

BACKGROUND: According to the literature, there is a steady increase in citizens' complaints about the quality of medical care.

AIM: The study aims to analyze the conclusions of forensic medical examinations of the most problematic groups of patients with acute injuries of the musculoskeletal system from the point of view of legal risk, to correlate adverse outcomes and common defects in medical care that are important in the legal assessment of the actions of a traumatologist, as well as to identify organizational measures to improve the quality of medical care.

METHODS: A sample analysis of 150 conclusions of the commission of forensic medical examinations was performed. All examinations were conducted in different expert institutions in Moscow and the Moscow region in the period from 2019–2023. A content analysis of regulatory legal documents regulating the activities in the provision of medical care to patients with an emergency injury has been performed. A correlation was made between the unfavorable outcome and the identified defects in the provision of medical care to patients with acute injuries. Due to the fact that these medical care defects are nominal, we have applied Pearson's χ².

RESULTS: In the analysis of expert opinions, in most cases, defects in the provision of medical care were identified — 137 (91.3%), of which 47 (31.3%) conclusions contain 2 or more defects simultaneously. In 49 cases (32.7%), the expert assessment of the nature of the damage and the treatment plan was influenced by a defect in the management of medical records; in 38 cases (25.3%) — defects in treatment; in 27 cases (18.0%) — defects in diagnosis; in 19 cases (12.6%) — defects in the organization of medical care. Diagnostic defects related to missed fractures were detected in 18 (12.0%) cases. Most of the diagnostic defects were noted at the outpatient stage of medical care provision in a trauma center. Among the reasons for incorrect diagnosis, the following can be distinguished: inattentive examination of the victim, incorrect description of radiographs by a radiologist or a later description (for the next day or more), the inability to perform more high-tech and other research methods other than X-ray, for example, computed tomography or ultrasound.

CONCLUSION: In emergency traumatology, the probability of an adverse outcome is most affected by treatment defects (the relative risk was 1.21 with 25.3% of treatment defects — from 0.776 to 2.307). In the specialty "traumatology and orthopedics", there is a need to create scientifically sound, relevant to modern requirements of medical activity, clinical guidelines for patients with injuries of the musculoskeletal system, as well as to develop protocols for the provision of medical care to patients with polytrauma.

Currently, there is an increase in the prevalence of autoimmune diseases. In particular, against the background of a decrease in the incidence of Helicobacter pylori associated gastritis, the number of patients with autoimmune gastritis increases. This is an autoimmune disease in which the destruction of the acid-producing gastric mucosa occurs due to the loss of parietal cells with their replacement by atrophic and metaplastic tissue, which leads to impaired absorption of iron, vitamin B₁₂, deficiency states, anemia, neurological disorders and the development of malignant tumors. It is not fully known what triggers aggression. It is assumed that the autoimmune process can occur due to the interaction of genetic and environmental factors. In addition, the relationship between H. pylori and the development of autoimmune gastritis has not been fully studied.

Diagnosis of autoimmune gastritis is based on serological markers, but its leading method is esophagogastroduodenoscopy with biopsy. Several endoscopic signs allow one to suspect autoimmune gastritis: reverse atrophy; the presence of islets of preserved acid-producing mucosa; viscous mucus; protrusions in the body of the stomach, which are currently called "white spheres"; glomus formations, which are a proliferation of enterochromaffin-like cells. Atrophy of the mucous membrane of the body of the stomach is detected in biopsy material; three stages of inflammation of the mucous membrane of the body of the stomach can also be observed. Patients with autoimmune gastritis have an increased risk of developing malignant neoplasms, namely type 1 neuroendocrine tumors and adenocarcinoma. Therefore, regular monitoring is necessary for the early detection of these pathologies. However, the monitoring intervals have not been definitively determined. Most sources indicate the need for gastroscopy once every 1–3 years.

Heart failure (HF) is an important medical, social and economic problem. The study of new biological markers deepens our understanding of the pathogenesis of this disease. In modern cardiology, there is a growing interest in matrix metalloproteinases (MMPs). These enzymes play an important role in tissue remodeling, angiogenesis, as well as in cell proliferation, migration and differentiation.

The purpose of this literature review is to analyze current experimental and clinical data on MMP-9 as a new diagnostic and prognostic marker in HF. This review presents an analysis of modern publications on a given topic. We conducted an analysis of literature sources covering all important materials as of 01.12.2024. Experimental studies have established that MMP-9 is a key participant in cardiac remodeling, since it is directly involved in the degradation of extracellular matrix proteins and the activation of profibrotic pathways, as well as cytokines and chemokines. Clinical trial data indicate the significant importance of MMP-9 for diagnosis and prognosis in patients with HF.

An analysis of scientific studies devoted to the problem of bariatric surgery in patients with stages IIIb–V as chronic kidney disease (CKD) as the main step towardspossible kidney transplantation is presented. Obesity leads to CKD both directly, acting as an independent risk factor, and indirectly, by increasing the risk of diabetes, hypertension and atherosclerosis (i.e., a group of independent risk factors for CKD). CKD with an outcome of chronic renal failure is the second most common cause of mortality and disability in obese patients. In most kidney transplantation centers, a body mass index of more than 40 kg/m² is a contraindication for to transplantation (refusal to be included on the waiting list); and a body mass index of more than 35 kg/m² is a relative contraindication. In some cases, bariatric surgery is the only way to perform organ transplantation. Direct indications for bariatric surgery in patients with morbid obesity undergoing hemodialysis therapy have been identified. The established diet before/after bariatric surgery with the inclusion of protein isolate is not the cause of protein overload in patients with CKD. Bariatric surgery is considered a safe treatment option for obesity in potential kidney transplant candidates, given their continued need for immunosuppressive therapy.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with various cardiovascular diseases, including arterial hypertension, chronic heart failure, and cardiac rhythm and conduction disorders. In some patients, preexisting bradycardia may not be directly related to OSA. Therefore, it is advisable to rule out OSA in patients referred for pacemaker implantation.

CLINICAL CASES DESCRIPTION: OSA is a common condition frequently associated with bradyarrhythmias. In some cases, treatment for such patients involves the implantation of a permanent endocardial pacemaker. Undiagnosed OSA may lead to an increased number of unnecessary pacemaker implantations, emphasizing the importance of timely diagnosis and treatment of this condition. This article presents clinical observations of seven patients with nocturnal bradyarrhythmias, which resolved following continuous positive airway pressure (CPAP) therapy.

The use of CPAP therapy contributed to the improvement of cardiovascular parameters, including the reduction in the number and duration of heart rhythm pauses. Clinically significant bradyarrhythmias were resolved in patients, allowing them to avoid surgical intervention. In the described cases, patients demonstrated a high apnea–hypopnea index (35.0–79.5 episodes per hour), a significant decrease in blood oxygen saturation (minimum up to 50%), and significant heart rhythm disturbances during the night. The initiation of CPAP therapy led to a reduction in the apnea–hypopnea index (1.9–23.1 episodes per hour), normalization of minimum oxygen saturation (80–93%), and the elimination of prolonged rhythm pauses.

CONCLUSION: The findings highlight the necessity of mandatory screening for OSA in patients with nocturnal bradyarrhythmias before planning pacemaker implantation. CPAP therapy effectively eliminates rhythm disturbances associated with sleep apnea and prevents unnecessary surgical procedures. This confirms the importance of a comprehensive approach to the diagnosis and treatment of this category of patients and the need for further large-scale studies to optimize their management tactics.