THE LATEST MODE OF DIAGNOSIS,

MANAGEMENT AND PREVENTION OF

ACUTE MENINGITIS

By Muhammad Yameen Hamid, AninditaGhosh

THE ETIOLOGICAL STRUCTURE AND

CLINICAL EPIDEMIOLOGICAL FEATURES

OF VIRAL MENINGOENCEPHALITIS IN

CHILDREN

By N.B.Tukhanova

MODULATION OF INTESTINAL TIGHT

JUNCTION PROTEINS BY NUTRIENTS

By Siti Sarah Binti Ahmad Shahidan, Mohammed

Nasimul Islam, Jesmine Khan

IDENTIFICATION OF SYMPTOMS OF A

STRESS AT STUDENTS DURING CARRYING

OUT IN EXAMS

By Akkazhieva N.N., Nuritdinova M.M.

ATRIAL FIBRILLATION AND VEGETATIVE

NERVOUS SYSTEM STATUS: PRE-HOSPITAL

TREATMENT AND MANAGEMENT TACTICS

By V.G. Epifanov, V.T. Dolgikh

INVESTIGATION OF STOMATITIS CAUSES

AMONG THE STUDENTS AND

DEVELOPMENT OF "PHYTOMEDICATION"

FOR THE PREVENTION AND TREATMENT

By D. Sharipov

CHANGING OF SUCCINATE

DEHYDROGENASE’S (SDH’S) ACTIVITY IN

HYPOTHYROIDISM OF NEWBORN AND

PREGNANT WOMEN

By M. Kulmaganbetov

p. 8

p. 16

p. 18

p. 23

p. 25

p. 33

p. 35

Toregeldy Sharmanov Sharmanovich was born on the 19th of

October of 1930, in village Ulytau, Karagandy province. After

excellent graduation of Karagandy State Medical University in

1995 and postgraduate studentship (1958-1962) he worked as a

chief doctor of Ulytau Central District Hospital of Karagandy

Province. Since 1962 till 1968 he was a chair of nutrition

department of research institute of endemic medicine of Health

Ministry of KazSSR. From 1968 to 1971 – vice-chancellor of

Aktyubinsk State Medicine Institute and at the same time a chair

of pharmacology department.

1971-1982 – Minister of Health Ministry of Kazakh SSR

From 1972 to these days – founder and president of Kazakh

Nutrition Academy. The academy is a center of comlplex research

involving a wide spectrum of problems of hygiene, biochemistry,

immunology, nutrition physiology, diet prevention and diet

therapy in the republics of Central Asia. T.S.Sharmanov is a

founder of the School of Nutritionists in Kazakhstan. He is a

director of international scientific and technological projects on

liquidation of iron deficiency anemia, iodine insufficient

condition, breast nutrition supporting, medical-demographic

investigations being lead in cooperation with international

organizations such as UN Children Fund, WHO, UN Development

Programme, USAID, Macro International Inc, Wilstart, etc.

During 1985 through 1988 he was a main editor of All-Soviet

Union magazine “Nutrition issues”, chair of nutrition department

of Central Institute of doctors’ enhancement in Moscow. From

May of 1995, he was a founder and president of the Academy of

Preventative Medicine.

He remains a head editor of the magazine “Health and decease”.

The Center of Children Nutrition that has no analogies on the area

of CIS was created under his direction, just like principally new

products of children nutrition were brought into practice, and a

range of decease-preventive products as well.

Thanks to the initiativity of T.S.Sharmanov and his efforts, in 1979 the nutrition Institute became first in the

world to cooperate with WHO in nutrition field, and since 1997 cooperating center of UN University. Thirty

six doctor and one hundred seventy PhD dissertations were defended under his supervision. T.Sharmanov

is an author of 350 publications including 25 monographs and 37 inventions. He was elected into the

Parliament of Republic of Kazakhstan for three times.

His son Almaz is a PhD in medicine, a citizen of the United States, diplomat, director of USAID Kazakhstan

mission, international health expert and a professor at Johns Hopkins University (USA), vice-president of

Nazarbayev University. He is a grandfather for three: Alua has graduated from Maryland University (USA),

married, living in USA, Torekhan – 19 years old, Askar – 17, and a great grandson Konnor, born in 2006.

Toregeldy Sharmanov Sharmanovich is a man who needs no presentation.

However, he prefers avoing various praises and mentioning his numerous

regalia that might be a subject of jealousy for any academician.

Toregeldy has always openly expressed and keeps expressing his criticizing his

extraordinary position towards not only the topical health-related issues, but

also the ethics of human relationships, social development and political

priorities.

It certainly must be the 12 years of being a health minister, also claimed as a

“golden age of our medicine”, that comprise the most unforgettable part of his

bio for us. Those were the years when he unfolded as a convinced, charismatic,

creative and willful leader. At that time he manages to create a unique

infrastructure of health service and a great human recourse potential that will

withstand the collapse of USSR and the following reforms. These achievements

received international acknowledgement during the historical conference

dedicated to rendering first medical help that was lead in Alma-Ata in 1978 in

presence of health minister from 140 countries. That conference has accepted

the Alma-ata declaration which is now being called a “Bible of world health

service”. For these merits twenty five years later Toregeldy Sharmanov was

entitled for the highest award of World Health Organization – Leon Bernar

medal which has been conferred for only 42 times during the entire history.

Toregeldy has actualized himself not only as a politician and public figure, but

also as a great scientist. His discoveries in the area of nutrition still remain

relevant to our days. He was the first academician from Central Asia who

became a member of the Academy of Medical Sciences of USSR. The science

collectivity of Kazakh Academy of Nutrition that was chaired by him for 35

years received acknowledgments from such reputable organizations as UN

Children Fund, UN Development Programme and many others.

Today Kazakh Academy of Nutrition puts a lot of effort on fighting anemia,

iodine insufficiency and other deceases of children and women.

Several generations of Kazakhstan people grew nourished by unique children

products, created by Toregeldy Sharmanov. Today these inventions are

implemented as a factory producing children nutrition that was constructed by

him in cooperation with foreign investors.

Politicians respect him. He is always at the center of media’s attention.

Colleagues praise him. Youth admires him. Relatives love him. As Toregeldy

Sharmanov says about himself, he feels that he is in a good shape and feels like

40 at his 83 years.

«ALMATY TURNING POINT OF WORLD HEALTH CARE»

Dedicated to the 30th anniversary of Alma-Ata WHO/UNICEF

Conference of 1978 named the most remarkable event in the

history of medicine and then adopted Alma-Ata Declaration –

«The Great Charter of World Health care»

Thirty years ago the Declaration of Alma

Ata articulated Primary Health Care as a

set of guiding values for health

development, a set of principles for the

organization of health services and a range

of approaches for addressing both priority

health needs and the fundamental

determinants of health.

It was conceived as a commitment to

universal access to services for protecting

and improving health status between and

within countries.

On the whole people are healthier today

and live longer than thirty years ago.

However, there is a deepening

dissatisfaction with health services

worldwide. Unprecedented commitment,

funds, technology and expertise have not

resulted in expected health outcomes.

Hundreds of millions of people still remain

without regular access to services.

More and more countries are turning

again to the values of Primary Health Care

as the basis for strengthening their health

systems.

In his capacity as Minister of Health of

the Kazakh Republic Professor Toregeldy

Sharmanov was one of the key organizers

of the Alma Ata conference which was co-

sponsored by the World Health

Organization and UNICEF. As author of

this book he offers readers unique

perspective on both the background and

follow up to the historic Alma Ata

conference.

On the occasion of the Thirtieth

Anniversary of the Declaration of Alma

Ata his insight provides a valuable

reference to today’s members of the

international health community as they

engage in the new worldwide movement to

revitalize Primary Health Care.

Dr Margaret Chan

Director Genera

World Health Organization

«Almaty Turning Point of World Health

Care»

ISJM

8 Issue 01 / September 2013 isjm.kaznmu.kz

THE LATEST MODE OF DIAGNOSIS, MANAGEMENT AND PREVENTION OF

ACUTE MENINGITIS

Prof. Dr. Maliha Hakim, Professors, Neurology Department, ShaheedSuhrawardy Medical College, Dhaka Dr. M TasdikHasan, Research Fellow, ICDDR,B Muhammad Yameen Hamid, 4th year, ShaheedSuhrawardy Medical College, Dhaka, Bangladesh E-mail: yhamid91@yahoo.com AninditaGhosh, 4th year, ShaheedSuhrawardy Medical College, Dhaka, Bangladesh

Abstract:

Introduction

Meningitis is an acute inflammation of

leptomeninges and CSF caused by

mainly bacteria, virus and less

commonly fungus which has 50% case

fatality rate if untreated. The most

common symptoms are a stiff neck, high

fever, sensitivity to light, confusion,

headaches and vomiting. Meningitis is

potentially fatal and should always be

viewed as a medical emergency. Thus

early diagnosis and effective

management of suspected cases of

meningitis will lead to significantly

reduction in mortality. In this article the

latest modes of diagnosis and treatment

have been discussed along with

preventive measure.

Method

This study was done by reviewing 15

journals, online clinical articles and

clinical books from June, 2013 to July,

2013.

Result

In laboratory investigation, CSF profile

shows different characteristics in

bacterial and viral etiology. CSF

pressure is elevated with low glucose

level; high protein level and

predominant neutrophil in bacterial

cause. In viral cause pressure is almost

normal, lymphocyte is predominant,

glucose and protein levels are normal.

PCR and ICT detecting bacterial DNA

show 100% specificity. CT or MRI is not

diagnostic usually. The latest treatment

plan includes empiric therapy, specific

therapy, adjunctive therapy by

Dexamethasone, outpatient

antimicrobial therapy & antiviral

therapy and treatment of special

situation. Empiric antimicrobial therapy

should be started as soon as possible

after diagnosis proven or suspected.

Specific therapy depends on Gram’s

staining and culture of CSF.

Ciprofloxacin is used successfully in

multidrug resistant gram-negative

bacilli. In HSV, VZV and CMV

meningitis acyclovir and ganciclovir is

given. Dexamethasone is effective in

bacterial meningitis as adjunctive

therapy. In special situation as in

fulminant meningococcemia

benzylpenicillin is drug of choice, in

increased ICP mannitol is administered

and patient is monitored ICU. Vaccines

that are available to control the disease

are meningococcal A conjugate vaccine,

C conjugate vaccines (MCV4),

tetravalent A, C, Y and W135 conjugate

vaccines and meningococcal

polysaccharide vaccines. Meningococcal

A conjugate vaccineelicited a stronger

response to group A antibody than the

tetravalent vaccine.

Discussion/Conclusion

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 9

Early recognition and initiation of

appropriate empiric therapy can reduce

the mortality to 10%. If rapid and

specific identification of the

etiologicagent is done and adjusting

therapies are given as indicated, it will

efficiently manage a patient with

meningitis. Optimize management is

possible in complicating features.

Prevention can be done in epidemic

areas by proper vaccination mentioning

MCV4 and HIB vaccine.

Key words

acute meningitis, empiric therapy,

adjunctive therapy, meningococcal

vaccine.

Introduction:

Meningitis is an acute inflammation of

leptomeninges and CSF caused by

mainly bacteria, virus and less

commonly fungus which has 50% case

fatality rate if untreated. The most

common symptoms are a stiff neck, high

fever, sensitivity to light, confusion,

headaches and vomiting. This disease

has worldwide distribution. But Sub

Saharan countries are labeled as

‘Meningitis belt’ due to overwhelming

epidemic of meningitis. It has a high

death rate with severe complications

such as mental retardation, difficulty in

hearing, which may disable the person

for life time. Meningitis is potentially

fatal and should always be viewed as a

medical emergency. Thus early

diagnosis and effective management of

suspected cases of meningitis will lead

to significantly reduction in mortality. In

this article the latest modes of diagnosis

and treatment have been discussed

along with preventive measure.[15][1][8]

Methods:This study was done by

reviewing 15 journals, online clinical

articles and clinical books from June,

2013 to July, 2013.

Body of the article:

Epidemiology:

Bacterial meningitis occurs in about 3

people per 100,000 annually in Western

countries. Sub-Saharan Africa

experienced large epidemics of

meningococcal meningitis for over a

century which is labeled the "meningitis

belt". Attack rates of 100–800 cases per

100,000 are encountered in this

area.[8]Regional averages ranged from 1

to 15 per 100,000 population in children

age one to four.[7]

The death rate of about 10% for treated

meningococcal meningitis occurs even

when the public is aware of the disease

and health care is prompt. In sub-

Saharan Africa, death rates as high as

30% have been reported. At least 75 000

children are likely to have sustained

central nervous system injury after cure

of their meningococcal meningitis. [9]

Etiology:

Meningitis usually results from a viral

infection, but the cause may also be a

bacterial infection. Less commonly, a

fungal infection may cause meningitis.

ISJM

10 Issue 01 / September 2013 isjm.kaznmu.kz

Because bacterial infections are the most

serious and can be life-threatening,

identifying the source of the infection is

an important part of developing a

treatment plan.[10]

Clinical assessment:

Classic clinical presentations are fever,

headache, stiff neck & alterations in

mental status.95% of patients with

culture-proven bacterial meningitis

present with at least two of these signs

or symptoms.Nuchal rigidity occurs in

70% of adult cases. There are some

special signs of

meningismincludingKernig’s sign,

Brudzinski’s sign and positive jolt

accentuation test.Other physical

examinations includeseizure activity,

signs of increased ICP, rash of

meningococcemia, signs of Fulminate

meningococcemia[1]

Evidence of severe meningeal irritation

is generallyabsent or minimal in viral

meningitis. Signs of encephalitis often

present in HSV-1. Viral meningitis is

usually self-limiting&

withoutneurological sequelae. [2]

Lab diagnosis:

Blood cultures positive in 50-60% cases

of bacterial meningitis & detect

Arbovirus, Enterovirus, and LCMV.[2]

CSF Analysis:

Gram’s stain demonstrates organisms in

>60% of untreated cases (specificity

>97%).CSF Culture are positive in (70-

85)% of untreated bacterial meningitis &

(30-70)% in viral meningitis.Latex

agglutination test is most useful for

pretreated patients & Gram’s stain &

CSF culture negative cases. Limulus

amebocyte lysate assay detects gram-

negativeendotoxin.[3]

PCR detects bacterial DNA in pretreated

& Gram’s stain & CSF culture negative

cases. PCR detects two-thirds of culture-

negative cases of viral etiology.[2] But

PCR and ICT shows 100% specificity in

detection of bacterial cases.[11]

In bacterial etiology following CSF

profile is found:

1. Elevated opening pressure:

>180 mmH2O in more than 90% of

patients

>400 mmH2Oin 20% of patients

2. Leukocyte count:

10/μL to 10,000/μL, neutrophil are

predominant

3. Glucose level: Low (< 40 mg/dL)

4. CSF/serum glucose ratio:< 0.4 in

60% of patients

5. Protein level: >45 mg/dL in 90% of

patients[2]

In viral etiology following CSF profile is

found:

1. Normal or mildly elevated opening

pressure: 100–350 mmH2O

2. Leukocyte count: <100–1000 cells

per μL, lymphocytes are

predominant

3. Protein level: Normal

4. Glucose level: Normal

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 11

In either bacterial or viral etiology

following CSF profile is found:

1. CSF lactate

concentration:>4.2mmol/L

2. Elevated CSF concentration of CRP

3. Elevated serum concentrations of the

polypeptideprocalcitonin[1]

CT or MRI is not diagnostic. MRI

preferred in demonstrating areas of

edema & ischemia. Meningeal

enhancement often seen [2]

Indication of CT prior to lumbar

puncture:

a. Immunocompromised state

b. History of Mass lesion, stroke, or

focal infection

c. New onset seizure (Within 1 week

of presentation)

d. Papilloedema (Presence of

venous pulsations suggests

absence of increased ICP)

e. Reduced level of consciousness

f. Focal neurologic deficit

g. Patients with coagulopathy &

taking anticoagulants [1]

Differential diagnosis:

Encephalitis

Subarachnoid haemorrhage

Septic thrombosis of the superior

sagittal sinus

Focal infectious intracranial mass

lesions[2]

Treatment plan:

a. Empiric therapy

b. Specific therapy

c. Adjunctive therapy:

Dexamethasone

d. Criteria for outpatient

antimicrobial therapy & antiviral

therapy

e. Treatment of special situation [3]

Empiric therapy:

Antimicrobial therapy is administered

before the patient’s level of

consciousness deteriorated to 10 on the

Glasgow Coma Scale to reduce mortality

& neurologic complication.[3]

Empiric antimicrobial therapy should be

initiated as soon as possible after

diagnosis proven or suspected.

Antimicrobial therapy should not await

CT or MRI or lumbar puncture. Blood

cultures should be obtained. Empiric

therapy should include a combination of

a third- or fourth-generation

cephalosporin plus vancomycin plus

Acyclovir. Ampicillin & gentamicin

should be added to the empiricregimen

in patients in whom L.

monocytogenesmay be the causative

organism. Doxycycline should be added

to the empiric regimen in patients with a

rash. Combination of

vancomycin&ceftazidime, cefepimeor

meropenemshould include in

neurosurgical patients & in hospital-

acquired meningitis. Increased ICP

should be managed emergently.[4]

Specific therapy:

ISJM

12 Issue 01 / September 2013 isjm.kaznmu.kz

Specific therapy isbased on positive

Gram’s stain or culture of cerebrospinal

fluid. Recommended specific therapy in

positive ram’s stain or culture of CSF is

given in the table:[5]

Type of bacteria (On Gram’s staining)

Choice of antibiotic

Cocci

Gram-positive Vancomycin plus broad- spectrum cephalosporin

Gram-negative

Penicillin G

Bacilli

Gram-positive Ampicillin (or penicillin G) plus aminoglycoside

Gram-negative Broad-spectrum cephalosporins plus aminoglycoside

Type of bacteria (On culture of CSF)

Choice of antibiotic

S. pneumonia Vancomycin plus broad-spectrum cephalosporin

H. influenza Ceftriaxone N. meningitides Penicillin G L. monocytogenes Ampicillin

plus gentamicin

S. agalactiae Penicillin G Enterobacteriaceae Broad-

spectrum cephalosporin plus aminoglycosid

e Pseudomonasaeruginosa

Ceftazidime plus aminoglycoside

Ciprofloxacin is used successfully

(limited published literature) in

multidrug resistant gram-negative

bacilli & in not responding or receiving

standard antimicrobial therapy.

Carbapenems are successfully used in

moderate resistant penicillin and

cephalosporin strains. Meropenem is

more preferable to imepenem due to less

seizure proclivity.[3]

Traditionally, a range of 7 to 10 days is

recommended for meningococcal

meningitis & longer courses (10 to 21

days) in other pathogens.[5]

Recommended specific therapy in

viral meningitis:

1. HSV-1 or -2, VZV:

Acyclovir 15–30 mg/kg per day IV in

3 divided doses. Oral drug therapies

may not have adequate CSF

penetration to adequately treat these

infections.

Acyclovir (800 mg, 5 times daily)

Famciclovir (500 mg)

Valacyclovir(1000 mg)

Duration: total course of 10–14

days

2. CMV meningitis:

Ganciclovir and/or Foscarnet

3. HIV meningitis:

Highly active antiretroviral therapy[2]

Adjunctive therapy:

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 13

Dexamethasone is administered as soon

as possible if lumbar puncture reveals

any of the following:

Frankly purulent CSF

CSF WBC count >1000/microlitre

Raised CSF WBC count with protein

concentration >1 g/litre

Bacteria on Gram stain [2]

Most likely to benefit are those with a

high concentration of bacteria in CSF

(positive Gram’s stain of CSF) and

evidence of increased ICP.[6]

The recommended dose is 0.6

mg/kg/day in 4 divided doses

(0.15mg/kg/dose) given intravenously

for the first 4 days of antibiotic therapy.

The first dose of dexamethasone should

be administered before or at least with

the first dose of antibiotic. Decrease

CNS concentration of vancomycin with

concurrent steroid use. Mortality to

pneumococcal meningitis reduced from

34% to 14%. Reduce fatality, hearing

loss & neurologicalsequelae.[3]

Patients with septic shock & adrenal

insufficiency get benefit from steroid

therapy in physiological doses & longer

duration. [1]

Criteria for outpatient

antimicrobial therapy:

Inpatient antimicrobial therapy for >

6 days

Absence of fever for at least 24 – 48

h prior to initiation of outpatient

therapy

No significant neurologic

dysfunction, focal findings or seizure

activity

Clinical stability or improving

condition

Ability to take fluids by mouth

Reliable intravenous line and

infusion device (if needed)

Availability of physician, nurse,

laboratory monitoring &

emergencies[3]

Criteria for outpatient in antiviral

therapy:

Immunocompetent patient with

presumed viral meningitis

No focal signs or symptoms

No significant alteration in

consciousness

Classic CSF profile

Adequate provision for monitoring at

home and medical follow-up can be

ensured[2]

Treatment of special situation:

1. Acute meningococcaemia:

Cases are isolated (if possible) until

they have had >12 hours antibiotic

treatment. Empiric therapy is

Cefotaxime or Chloramphenicol

alternative. Benzylpenicillin is

specific drug. Often peripheral

perfusion is needed 40 ml/kg or

more in the first hour.

2. Fulminant meningococcemia:

Drug of choice is Benzylpenicillinand

Chloramphenicol is alternative.

Ceftriaxone is commonly employed

today. Hydrocortisone is used for

ISJM

14 Issue 01 / September 2013 isjm.kaznmu.kz

hypoadrenal shock. Plastic surgery

and grafting is done in tissue

necrosis.

3. Increased ICP:

Patient’s head should be elevated at

30° to 45°. Intubation is done in

hyperventilation (PCO2 25–30

mmHg). Mannitolis administered.

Patient is monitored ICU.Use ICP

monitoring device for accurate

monitoring possibly drainage of CSF [2]

Complications:

Bacterial meningitis results in

substantial morbidity and mortality

despite the availability of effective

antimicrobial therapy. Complications

due to bacterial meningitis can be

divided into systemic and neurologic.

Systemic complications such as septic

shock, disseminated intravascular

coagulation, acute respiratory distress

syndrome, and septic or reactive

arthritis, are usually the consequence of

the bacteremia that frequently

accompanies meningitis. The neurologic

complications of bacterial meningitis

include:

Impaired mental status

Increased intracranial pressure and

cerebral edema

Seizures

Focal neurologic deficits (eg, cranial

nerve palsy, hemiparesis)

Cerebrovascular abnormalities

Sensorineural hearing loss

Intellectual impairment[12] [13]

Prevention:

Meningitis typically results from

contagious infections. Common bacteria

or viruses that can cause meningitis can

spread through coughing, sneezing,

kissing, or sharing eating utensils, a

toothbrush or a cigarette. A person is

also at increased risk if he lives or works

with someone who has the disease.

These steps can help prevent meningitis:

Wash your hands

Practice good hygiene

Stay healthy

Cover your mouth during cough or

sneeze

Immunizations:

Some forms of bacterial meningitis are

preventable with the following

vaccinations:

Haemophilusinfluenzae type b

(Hib): vaccine. Children in the

United States routinely receive this

vaccine as part of the recommended

schedule of vaccines.

Pneumococcal conjugate vaccine

(PCV7): This vaccine is part of the

regular immunization schedule for

children younger than 2 years in the

United States

Haemophilusinfluenzae type b and

Neisseria meningitidisserogroups C

and Y vaccine (Hib-MenCY)

Pneumococcal polysaccharide

vaccine (PPSV)

Meningococcal conjugate vaccine

(MCV4)

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 15

This vaccine can also be given to

younger children who are at high risk of

bacterial meningitis or who have been

exposed to someone with the disease.

It's approved for use in children as

young as 9 months old. It's also used to

vaccinate healthy people who have been

exposed in outbreaks but have not been

previously vaccinated. [10]

Meningococcal A conjugate

vaccineelicited a stronger response to

group A antibody than the tetravalent

vaccine.[14]

Conclusion:

Early recognition and initiation of

appropriate empiric therapy can reduce

the mortality to 10%. If rapid and

specific identification of the

etiologicagent is done and adjusting

therapies are given as indicated, it will

efficiently manage a patient with

meningitis. Optimize management is

possible in complicating features.

Prevention can be done in epidemic

areas by proper vaccination mentioning

MCV4 and HIB vaccine.

References:

1. Infection thelancet.com Volume 7,

March 2007

2. Harrison’s Principles of Internal

Medicine, 17th edition

3. Tunkel et al., Practice Guidelines for

Bacterial Meningitis,CID 2004:39 (1

November)

4. Saunders manual of Neurologic

Practice

5. The New England Journal of

Medicine, 712, March 6, 1997

6. The New England Journal of

Medicine; Volume 336 Number 10

7. http://www.ncbi.nlm.nih.gov/books

/NBK11768/

8. http://en.wikipedia.com/meningitis

9. Bulletin of the World Health

Organization 2003, 81 (10)

10. http://www.mayoclinic.com/health/

meningitis/

11. Bangladesh J Microbiol, Volume 24,

Number 1, June 2007, pp 24-29

12. Pfister HW, Feiden W, Einhäupl

KM. Spectrum of complications

during bacterial meningitis in adults.

Results of a prospective clinical

study. Arch Neurol 1993; 50:575.

13. Durand ML, Calderwood SB, Weber

DJ, et al. Acute bacterial meningitis

in adults. A review of 493 episodes.

N Engl J Med 1993; 328:21

14. N Engl J Med 2011; 364:2293-2304

15. http://www.who.int/mediacentre/fa

ctsheets/fs141/en/index.htm

ISJM

16 Issue 01 / September 2013 isjm.kaznmu.kz

THE ETIOLOGICAL STRUCTURE AND CLINICAL EPIDEMIOLOGICAL

FEATURES OF VIRAL MENINGOENCEPHALITIS IN CHILDREN

N.B.Tukhanova E-mail: beautiful_nur@mail.ru Kazakh National Medical University named after S.D Asfendiyarov, Almaty, Kazakhstan

Keywords: viral meningoencephalitis, children.

Actuality

Viral meningoencephalitis in children are not only life-threatening conditions, but also has social importance as the impact on future child’s devolopment social adaptation. The viral meningoencephalitis are 25-38% in the structure of infections diseases of the nervous system. Many of them are characterized by severe, high probability of gross residual central nervous system and significant mortality. The difficulties in the diagnosis of viral infection of the central nervous system, especially in babies, limited of etiotropic drugs, complications leading to disability and child mortality and responsible for high urgency of the problem of viral encephalitis;

Aim of study

To analyse the etiology structure and epidemiological, clinical viral meningoencephalitis in children period of 2001-2010 year hospitalized in Children Infection Diseases Hospital in Almaty.

Materials and method

We have studied 48 patients since 0 to 14 years old, who had admitted to department Infection Diseases Hospital, is there: herpesmeningoencephalitis – 18,8%, CMV meningoencephalitis –

12,5%,measlesmeningoencephalitis – 8,3%, mixed meningoencephalitis (Herpes+CMV) – 29,2%,unknown etiologymeningoencephalitis – 31,2%.

The majority of cases the children were under 6 months of age 45,8%, the least number of cases were children from 4-6 years – 6,3%.

All children admitted complications premorbid background, mostly anemia 31.2%, pathology of pregnancy and childbirth 22.9%. In the analysis of cerebrospinal fluid in patients with viral meningoencephalitis – 83% of the cases observed lymphocytic pleocytosis and increased protein. The major complications of herpes virus, CMV and mixed meningoencephalitis in children has been the development of edema, hemi-paraparesis and atrophic changes in the brain

Fatalities in viral meningoencephalitis came 1/3 cases, they were mostly children under the age of 6 months. In all cases, death occurred due to the development of edema and swelling of the brain, organ failure

Conclusions:

1. Viral meningoencephalitis occurs in children with complicated background;

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 17

2. The most of the children were of the first six months of life – 45,8%;

3. In the etiological structure of more than met mixed meningoencephalitis29,2%

4. The main complications of viral encephalitis in children has been the development of edema,hemi-paraparesis and atrophic changes in the brain;

The 31,2% of patients had fatal issues.

ISJM

18 Issue 01 / September 2013 isjm.kaznmu.kz

MODULATION OF INTESTINAL TIGHT JUNCTION PROTEINS BY NUTRIENTS

Siti Sarah Binti Ahmad Shahidan, Mohammed Nasimul Islam, Jesmine Khan.

E-mail: ctsarahza@gmail.com

Faculty of Medicine, Universiti Teknologi MARA (UiTM)

Sungai Buloh, Selangor, Malaysia

Introduction

Beside its main function of digestion and

absorption, intestinal mucosa acts as an

important barrier to toxic and harmful

materials and protects an individual from

different antigenic and inflammatory

reactions. The intestinal barrier is

composed of a mucin layer covering the

cells, enterocytes and the apical junctional

complex between cells (Nusrat A 2000).

The apical junctional complex consists of a

network of tight junction proteins and the

adherens junction (Mitic LL 1998). They are

anchored in the cell via the filamentous

actin cytoskeleton (Ivanov A 2004). Zonula

occludens proteins (ZO-1, ZO-2 and ZO-3)

are important intracellular tight junction

proteins, linking the cell cytoskeleton to the

transmembrane TJ proteins such as

claudins, occludin and junctional adhesion

molecules (JAM). Whereas occludin and

JAM have a regulatory role, transmembrane

protein claudins, abundantly present

between adjacent healthy intestinal

epithelial cells, are mainly responsible for

the intestinal barrier function (Turksen K

2004). Recently, disruption of the above

mentioned structures during several

physiological or pathological conditions has

been reported, which were associated with

impaired intestinal barrier function and

lead to the passage of intraluminal solutes

into the systemic circulation (Rahner C

2001, Saudi WSW 2009, Suzuki T 2010).

Investigations showed that the changes of

intestinal barrier function were mainly due

to the relaxation of the tight-junction

between intestinal epithelial cells

(Gasbarrini G 1999).

Objective of the study

To review whether intestinal disrupted

TJP can be modified or returned back to

normal by nutrients.

Materials and Methods

We found a total of 112 studies using the key

words, claudin, occludin, junctional

adhesion molecule, intestinal tight junction

proteins and nutrients. Most of the studies

dealt with the effect of probiotics on

intestinal TJP. To include and discuss all the

studies is beyond the scope of this poster.

Hence, we will give an overall idea of the

effects of nutrients on the intestinal TJP.

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 19

Results

Table I: Effect of different nutrients on modulating the tight junction proteins of gastrointestinal barrier.

Nutrients Methods used Findings Author

Glutamine Electron microscopy Prevented total

parenteral nutrition

induced loss of ZO-1

expression along the

apical surface of

intestinal epithelial cells

in rats.

Nose K 2010

Zinc

Electron microscopy Percentage of the

disrupted tight

junctions in

experimental colitis

were reduced by 50%

with zinc in mice.

Sturniolo GC 2002

Vitamin A PCR Treatment with retinoic

acid enhanced the

expression of claudin-2

of intestinal Caco-2

cells.

Baltes S 2004

Probiotics RT PCR Prevented acute colitis

induced decreased

expression and

redistribution of tight

junction proteins

occludin, zonula

occludens-1, and

claudin-1, -3, -4, and -5

in mice.

Mennigen R 2009

Prebiotics

qPCR and

immunohistochemistry

Improved tight-

junction ZO-1 and

occludin in mice.

Schedle K 2008

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20 Issue 01 / September 2013 isjm.kaznmu.kz

Quercetin

Confocal microscope

observation

Promotes the assembly

of TJ proteins, ZO-2,

occludin, and claudin-1

and the expression of

claudin-4 in Caco-2

Cells.

Suzuki T 2009

Transforming growth

factor-β, a whey protein

component

Real time PCR Increase the claudin-4

protein level of HT-

29/B6 cell monolayers.

Hering NA 2011

Discussion

In our literature search, several nutrients have been found to modulate intestinal TJP namely, glutamine, zinc, probiotics, prebiotics, vitamin A. Although there are lots of nutrients available, many are not investigated yet. Below we discuss few nutrients found to have modulating effect on intestinal TJP.

Glutamine

Glutamine is an amino acid important for the growth of enterocytes. Electron microscopy of the intestine in a GLN-deprived infant rat model demonstrates intestinal intercellular junction breakdown (Potsic B 2002).

Zinc

Trace elements such as zinc may assist in the maintenance of intestinal barrier integrity. Caco-2 cells grown in zinc-deficient media had reduced TEER and altered expression of ZO-1 and occludin ie. localized away from the cell boundaries and less homogenicity as compared with the Caco-2 cells grown in zinc-replete media. (Finamore A 2008).

Vitamin A

Vitamin A and retinoids are essential

nutrients for the differentiation of epithelia.

Vitamin A deficiency is accompanied by

impairment in intestinal integrity.

Treatment with RA had only a slight effect

on the mRNA expression of the tight

junction-associated proteins occludin, ZO-1,

claudin-1, -3, and -4, but enhanced the

expression of claudin-2, which was recently

suggested to form a paracellular ion channel

(Baltes S 2004).

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 21

Probiotic

Probiotics are living bacteria that, when

ingested in sufficient quantity, improve the

health of the host beyond their inherent

basic nutrition. In acute colitis, decreased

expression and redistribution of the tight

junction proteins occludin, zonula

occludens-1, and claudin-1, -3, -4, and -5

were observed, whereas VSL#3, a mixture of

8 probiotic bacterial strains therapy

prevented these changes (Mennigen R

2009).

Prebiotic

Prebiotic treated mice exhibited a decreased

hepatic expression of inflammatory and

oxidative stress markers. This decreased

inflammatory tone was associated with a

lower intestinal permeability and improved

tight-junction ZO-1 and occluding integrity

compared to controls (Schedle K 2008).

Flavonoid

Quercetin is the most common flavonoid in

nature. High amounts of quercetin are

found in onions, kale, and apples.

Flavonoids, quercetin and myricetin,

enhance barrier function in intestinal Caco-

2 cells. (Suzuki T 2009). Kaempferol, a

natural flavonoid present in fruits,

vegetables, and teas, provides beneficial

effects for human health. Confocal

microscopy showed that kaempferol-

induced assembly of occludin and claudin-3

occurred at the TJ of Caco -2 cells at 6 h

post administration (Suzuki T 2011).

Whey protein and casein peptide

Transforming growth factor-β, a whey

protein component, increase in the claudin-

4 protein level of HT-29/B6 cell monolayers

observed by real time PCR method (Hering

NA 2011).Casein peptide up-regulated the

expression of the occludin gene in cells, but

the level of the genes of the claudin family

and zonula occludens-1 (ZO-1) was

unchanged. Increased protein expression of

occludin, but not of claudin-1 or of ZO-1,

was also observed in Caco-2 cells using the

microarray method (Yasumatsu 2010).

Conclusion

Although still at the conceptual level,

evidences are persuasive that use of the

certain compounds, such as zinc, glutamine,

probiotics etc has the potential to attenuate

morphological changes by the above factors

and might represent a simple device to

prevent the occurrence or aggravation of

chronic pathologies caused by intestinal

barrier dysfunction. Future researches are

suggested to deal with the effect of several

other modulating agents on the intestinal

TJP. Therapeutic restoration of barrier

function could improve pathophysiology

and clinical outcomes of different diseases.

References

Nusrat A, Turner JR, Madara JL (2000) Molecular

physiology and pathophysiology of tight junctions. IV.

Regulation of tight junctions by extracellular stimuli:

nutrients, cytokines, and immune cells. Am J Physiol

Gastrointest Liver Physiol 279(5):G851-7.

Mitic LL, Anderson JM (1998) Molecular architecture of

tight junctions. Annu Rev Physiol 60:121-42.

Ivanov AI, McCall IC, Parkos CA, Nusrat A (2004) Role for

actin filament turnover and a myosin II motor in

cytoskeleton-driven disassembly of the epithelial apical

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22 Issue 01 / September 2013 isjm.kaznmu.kz

junctional complex. Mol Biol Cell 15(6):2639-51. Epub 2004

Mar 26

Turksen K, Troy TC (2004) Barriers built on claudins. J Cell

Sci. 117:2435–2447

Rahner C, Mitic LL, Anderson JM (2001) Heterogeneity in

expression and subcellular localization of claudins 2, 3, 4,

and 5 in the rat liver, pancreas, and gut. Gastroenterology

120(2):411-422

Saudi WSW, Khan J, Islam MN (2009) Small intestinal

morphology and permeability in chronic water avoidance

stress in rats. IMJ16(2), 87-91

Suzuki T, Hara H (2010) Dietary fat and bile juice, but not

obesity, are responsible for the increase in small intestinal

permeability induced through the suppression of tight

junction protein expression in LETO and OLETF rats. Nutr

Metab (Lond) 12;7-19

Gasbarrini G, Montalto M (1999) Structure and function of

tight junctions. Role in intestinal barrier. Ital J Gastroenterol

Hepatol.1999 Aug-Sep;31(6):481-8.

Nose K, Yang H, Sun X, Nose S, Koga H, Feng Y, Miyasaka E,

Teitelbaum DH.Glutamine prevents total parenteral

nutrition-associated changes to intraepithelial lymphocyte

phenotype and function: a potential mechanism for the

preservation of epithelial barrier function. J Interferon

Cytokine Res. 2010 Feb;30(2):67-80.

Sturniolo GC, Fries W, Mazzon E, Di Leo V, Barollo M,

D'inca R (2002) Effect of zinc supplementation on intestinal

permeability in experimental colitis. J Lab Clin Med

139: 311–315.

Baltes S, Nau H, Lampen A. All-trans retinoic acid enhances

differentiation and influences permeability of intestinal

Caco-2 cells under serum-free conditions. Dev Growth

Differ. 2004 Dec;46(6):503-14.

Mennigen R, Nolte K, Rijcken E, Utech M, Loeffler B,

Senninger N, Bruewer M. Probiotic mixture VSL#3 protects

the epithelial barrier by maintaining tight junction protein

expression and preventing apoptosis in a murine model of

colitis. Am J Physiol Gastrointest Liver Physiol. 2009

May;296(5):G1140-9. doi: 10.1152/ajpgi.90534.2008. Epub

2009 Feb 12.

Schedle K, Pfaffl MW, Plitzner C, Meyer HH, Windisch W

(2008) Effect of insoluble fibre on intestinal morphology and

mRNA expression pattern of inflammatory, cell cycle and

growth marker genes in a piglet model. Arch Anim Nutr.

62(6):427-38.

Suzuki T, Hara H (2009) Quercetin Enhances Intestinal

Barrier Function through the Assembly of Zonnula

Occludens-2, Occludin, and Claudin-1 and the Expression of

Claudin-4 in Caco-2 Cells. J Nutr: 139(5), 965-97

Takuya Suzuki, Soichi Tanabe and Hiroshi Hara (2011)

Kaempferol Enhances Intestinal Barrier Function through

the Cytoskeletal Association and Expression of Tight

Junction Proteins in Caco-2 Cells. J Nutr: 141(1), 187-94

Vreeburg RA, van Wezel EE, Ocaña-Calahorro F, Mes JJ.

Apple extract induces increased epithelial resistance and

claudin 4 expression in Caco-2 cells. J Sci Food Agric. 2012

Jan 30;92(2):439-44. doi: 10.1002/jsfa.4598. Epub 2011 Oct

3.

Hering NA, Andres S, Fromm A, van Tol EA, Amasheh M,

Mankertz J, Fromm M, Schulzke JD.Transforming growth

factor-β, a whey protein component, strengthens the

intestinal barrier by upregulating claudin-4 in HT-29/B6

cells. J Nutr. 2011 May;141(5):783-9. doi:

10.3945/jn.110.137588. Epub 2011 Mar 23.

Yasumatsu H, Tanabe S.The casein peptide Asn-Pro-Trp-

Asp-Gln enforces the intestinal tight junction partly by

increasing occludin expression in Caco-2 cells. Br J Nutr.

2010 Oct;104(7):951-6. doi: 10.1017/S0007114510001698.

Epub 2010 May 19.

Finamore A, Massimi M, Conti Devirgiliis L, Mengheri E

(2008) Zinc deficiency induces membrane barrier damage

and increases neutrophil transmigration in Caco-2 cells. J

Nutr 138:1664–70.

Lihua Wang, Yuzhu Tang, Deborah C. Rubin, and Marc S.

Levin (2007) Chronically administered retinoic acid has

trophic effects in the rat small intestine and promotes

adaptation in a resection model of short bowel syndrome.

Am J Physiol Gastrointest Liver Physiol. 292(6):G1559-69.

Epub 2007 Feb 15.

M Zareie, K Johnson Henry, J Jury, PC Yang, BY Ngan, D M

McKay, J D Soderholm, M H Perdue, and P M Sherman

(2006) Probiotics prevent bacterial translocation and

improve intestinal barrier function in rats following chronic

psychological stress. Gut: 55(11): 1553–1560.

Schedle K, Pfaffl MW, Plitzner C, Meyer HH, Windisch W

(2008) Effect of insoluble fibre on intestinal morphology and

mRNA expression pattern of inflammatory, cell cycle and

growth marker genes in a piglet model. Arch Anim Nutr.

62(6):427-38.

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 23

IDENTIFICATION OF SYMPTOMS

OF A STRESS AT STUDENTS

DURING CARRYING OUT IN

EXAMS

Akkazhieva N.N., Nuritdinova M.M.

E-mail: nagimysha_94@mail.ru

Scientific supervisors: Xasenova K.X., Biserovad

S.D Asfendiyarov Kazakh National Medical

University, Almaty, Kazakhstan

Actuality

It is shown that at a stress various

physiological functions are broken down

in works of foreign scientists. Our

university transited on credit system

from this year, according to which the

greatest attention is given to

independent work at acquisition of

knowledge of students, in this regard the

number of lectures and a practical

training was sharply reduced, duration

of a term made to 15 weeks. As a result,

the emotional and academic loading

increased on students. And to those

students to whom aren't indifferent their

estimates, it is necessary to strain

considerably during exams which we

pass nearly an every week. A revealing

the changes happening at us in our

organism during adaptation to

educational process was aim of our task.

Methods and material of research

The main method of work was to

conduct a two- stage survey of 50

students of 2nd course of the faculty

general medicine during regular

sessions within 15-19 November 2012

and at the time of control with a

landmark 22-29 November 2012 for

the studied subjects physiology and

biochemistry. Determined the

following performance:

1. Pulse rate - per minute;

2. Consentration of attention;

3. Level of memory;

4. Estimate the internal state of the

adapted Coleman test.

Results of research

We observed that majority of students

(93%) has a small increase of frequency

of the pulse in minute till 73-81 during

delivery of exams, whereas:

1. Pulse rate is about 70-77 in rest.

2. Consecration of attention to

extraneous stimuli (tables to determine

attention) during quiz reduced for 16%

than in the rest.

3. The number of students which

showed the excellent level of memory in

rest and during delivery of control is

observed from 46% from 100% to 29%

from 100% .

4. During control among students the

level of irritability is increased from 34%

to 41%, i.e. for 7% is observed.

Conclusion

It is possible on the basis of results

of research to assume that exams

acting as a stressful factor can have

negative impact on an organism of

students. The influence of stress

factor amplifies during session and

we can judge a condition of an

organism of students during this

period. All feel an emotional stress

differently therefore it is necessary

to adapt ourselves for such

influences since continuous

influences such can lead to

ISJM

24 Issue 01 / September 2013 isjm.kaznmu.kz

development of various

pathological conditions gradually.

Thus, planned the exams, carried

out during a semester, adaptations

of an organism of students to the

forthcoming examinations promote.

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 25

ATRIAL FIBRILLATION AND VEGETATIVE NERVOUS SYSTEM STATUS:

PRE-HOSPITAL TREATMENT AND MANAGEMENT TACTICS

V.G. Epifanov, V.T. Dolgikh

Omsk State Medical Academy, Lenin Str. 12, Omsk 644043, Russia

Epifanov V.G. — post-graduate student the Omsk State Medical Academy. Krasnoznamennaya Str. 20, apt. 19, Omsk 644013,

Russia. Phone: (3812) 60-01-14. Mobile phone: 8-904-321-1763. E-mail: slava-smp@mail.ru

Dolgikh V.T. — Honored Science Worker of the Russian Federation, Academician of the Russian Academy of Medical-Technical

Sciences, Doctor of Medical Sciences, Professor, holder of the Chair of Physiopathology with a course in clinical physiopathology at

the Omsk State Medical Academy. Lenin Str. 12, Omsk 644043, Russia. Phone: (3821) 23-03-78

Mobile phone: 8-913-155-28-60. E-mail: prof_dolgih@mail.ru

Keywords: atrial fibrillation, acute medical care at pre-hospital stage, vegetative tonus.

Abstract

A comparative retrospective study of

1009 cases of acute care rendered to

patients with atrial fibrillation episodes

was made, and tactics of pre-hospital

management of such patients were

evaluated. It was shown that the onset of

atrial fibrillation episode at pre-hospital

stage is accompanied by a pronounced

vegetative imbalance. Antiarrhythmic

therapy of atrial fibrillation with

diazepam rapidly reduces

sympathicotonia at pre-hospital stage

and increases the treatment efficacy in

the first hour of the patient’s follow-up.

Introduction

Atrial fibrillation (AF) is the most

common cardiac arrhythmia

encountered in clinical practice,

particularly in the practice of acute care

doctor. AF accounts nearly for one third

of hospitalizations due to cardiac

rhythm disturbances [5]. In two recent

decades, the admission rate of AF

patients has risen by a factor of 2-3; on

the one hand, this increased the

treatment cost, and on the other hand,

led to the development of novel

therapies for this category of patients

[4].

Among patients with cardiovascular

pathology who appealed for acute

medical care, those with AF episodes

constitute about 10%. The prevalence of

atrial fibrillation in a general population

amounts to 0.5%, increases with age and

in the presence of organic heart

pathology, and exceeds 6% among

persons older than 80. 23.3% of patients

with paroxysmal and 28.4% with

persistent AF show the increased clinical

anxiety and depression as compared to

patients without heart rhythm

disturbances [3]. An important role of

psychovegetative disorders in patients

with paroxysmal AF was proved; in

some paroxysmal AF patients, an

obvious similarity between subjective

symptoms of AF episode and the

symptoms of a panic attack was

demonstrated [6]. The development of

atrial fibrillation and related changes in

the life pattern (disabling,

hospitalization, etc.) may give rise to

pronounced mental troubles in patients

[8].

As early as in the 1950s, a relation

between AF onset and tonus of the

vegetative nervous system was reported

[10]. Further studies proved empirically

that electrophysiological properties of

cardiomyocytes can be impaired under

the action of vegetative nervous system,

and AF paroxysms can be caused by

changes in the vegetative tonus. Vagal

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26 Issue 01 / September 2013 isjm.kaznmu.kz

and sympathetic effects modulate

electrophysiological characteristics of

the atrial cells (duration of the action

potential, refractoriness, and conduction

velocity). Parasympathetic stimuli

facilitate the re-entry mechanism,

whereas sympathetic stimuli promote

the trigger activity [9].

Psychoneurological disorders aggravate

the course of atrial fibrillation,

complicate the clinical presentation,

increase the rate of emergency calls,

raise the number of unnecessary assays

and hospitalizations, and strongly affect

the patients’ quality of life [8].

Evidently, topicality of the problem of

psychosomatic disorders observed in AF

patients is determined not only by their

prevalence and disadapting effect, but

also by the fact that timely treatment of

these disorders often becomes a crucial

factor in efficacious therapeutic and

particularly acute care. This makes

pathogenetically valid the use of

psychopharmacological preparations

normalizing the tonus of the vegetative

nervous system during pre-hospital

acute care rendered to patients with AF

episodes.

In this connection, taking into account

the current reform of acute care service

and the usual shortage of time at pre-

hospital stage, the problems of acute

therapy and management tactics applied

to atrial fibrillation patients at pre-

hospital stage are very important.

Aim of the study

Using a comparative retrospective

analysis of the therapy data for patients

with atrial fibrillation episodes, to study

the efficacy of combined administration

of antiarrhythmic preparations and

diazepam during acute medical care and

evaluate the tactics of patients’

management and the state of vegetative

nervous system in this category of

patients at pre-hospital stage.

Materials and Methods

The comparative retrospective study

considered the results of acute medical

care rendered to 1009 patients with

uncomplicated atrial fibrillation

episodes lasting up to 24 hours. Of

them, 903 patients (the 1st group)

received only antiarrhythmic

preparations, and 106 patients (the 2nd

group) received a combined therapy

with antiarrhythmics and diazepam. The

duration of a single AF episode ranged

from 30 minutes to 28 hours, the

duration of “arrhythmic anamnesis”

lasted from 2-3 months to 27 years. The

mean age of the patients was 68.3±10.93

years (from 22 to 96). The analysis was

made using the cards of emergency calls,

outpatient cards from polyclinics, and

case histories from hospitals.

The study was performed using the

methods available at pre-hospital stage.

To evaluate the initial and final (after

therapy) vegetative status of patients,

the vegetative Kerdo index (VI) was

calculated, and blood minute volume

(MV) was examined by the Lilye-

Shtrander and Zander indirect method.

The Hildebrand coefficient (Q) was

employed to calculate intersystem

cardiorespiratory ratios [1].

Electrocardiographic control and

recording of arterial pressure (AP) were

performed over the entire follow-up

period.

In all the patients appealed for acute

medical care, the arrhythmia episodes

had no complications that would require

urgent electrical cardioversion.

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 27

In both groups, antiarrhythmic therapy

was performed with the preparations

included in the Standards for Acute

Medical Care [7]. The AF episode was

stopped by intravenous injection of

cordarone (amiodarone, KRKA) in a

single dose of 5 mg/kg, novocainamide

(procainamide, Organics) at a dose of

0.5-1 g, verapamil 5-10 mg (0.1 mg/kg

on the average) (Alkaloid), digoxin

0.25 mg (Nycomed), diazepam 10 mg

(seduxen, Gedeon Richter; relium,

Ciech; sibazon, Organics).

Antiarrhythmics were administered with

preliminary injection of 10 ml panangin

(Gedeon Richter). Action of the

preparations was evaluated for 50-70

minutes (on the average, for 64.1±3.2

min). The entire period of follow-up was

accompanied by ECG control and

recording of arterial pressure.

Check points of the study were as

follows: 1 h (the period of emergency

team work and patient’s follow-up), 12

and 24 h. The values are given as a mean

± standard error (M±σ). The mean time

needed to stop an AF episode and the

values of vegetative Kerdo index are

presented as “lower quartile – median –

upper quartile” (LQ-Me-UQ). Statistical

processing of the data was made using

the Mann-Whitney Test to compare

clinical parameters of the groups,

Wilcoxon Test to compare the

parameters in each group before and

after therapy, Chi-square Test) and

Fisher's Exact Test 2-tailed P to

compare the groups of patients with

respect to the relative rate of

administered antiarrhythmic

preparations. Methods of survival rate

analysis were applied: Cox's F-test and

the Cox’s regression model of

proportional intensities. Interrelations

between samples were analyzed using

the Spearman rank correlation (ρ) with

subsequent comparison of the

correlation coefficients to determine

whether their differences are stochastic.

The confidence interval taken as

statistically significant in this study was

equal to 95% (the significance level of p

was 0.05). Statistical analysis was

performed using the programs XLSTAT

2009 v. 3.02 (Addinsoft) and

STATISTICA v. 8.0 (StatSoft, Inc.) and

tabular processor Microsoft Office Excel

2010.

Results

Patients from both groups were found to

be comparable in age (Mann-

WhitneyTestp1-2=0,64), sex, diseases

that caused AF (Fisher'sExactTestp1-

2˃ 0,3), main clinical and hemodynamic

parameters, and antiarrhythmic

preparations used for medical care (Chi-

squaretestp1-4 = 0.27).

During the period of emergency team

work and patient’s follow-up, both

groups showed a marked improvement

in the clinical parameters. A decrease in

the heartbeat rate (HBR) and

respiratory rate (RR) was more

pronounced in the 2nd group of patients,

with statistically significant differences

between the groups (Table 1).

Within the first hour of the patients’

follow-up, the rhythm was restored in

20.9% of cases in the 1st group and in

40.6% cases in the 2nd group

(Fisher'sExactTestp1-2 = 0.0011). High

initial values of the vegetative index and

blood minute volume in both groups

indicated the pronounced

sympathicotonia (Table 1). The

Hildebrand coefficient in AF patients

was beyond the normal values, which

ISJM

28 Issue 01 / September 2013 isjm.kaznmu.kz

testifies to discoordination of vegetative

provision of respiratory and cardial

systems. By the end of the first hour of

follow-up, the improvement in

cardiorespiratory ratio and abatement of

sympathicotonia in the 2nd group, where

antiarrhythmic preparations were

administered in combination with

diazepam, were more pronounced than

in the 1st group. After acute care, the

value of vegetative index in the 2nd

group was 2.4 times lower as compared

to the 1st group (Table 1). In the 2nd

group, a moderate and reliable

(p < 0.0001) direct correlation

(ρVI = 0.4467 and ρMV = 0.4222)

between time of relieving the AF

paroxysm and decreasing the vegetative

index and blood minute volume was

observed. In the 1st group, the

correlation was absent (ρVI = 0.0365 at

p = 0.2617 and ρMV = 0.0315 at

p = 0.3333). The correlation coefficients

were different at a high level of

statistical significance (p < 0.0001). By

the 12th and 24th hours of follow-up, the

samples being compared had identical

characteristics of the AF paroxysm relief

time (Table 2). Such results can be

attributed not only to antiarrhythmic

therapy, but also to the fact that

spontaneous conversion of the paroxysm

may attain 66% in patients within 24 h

after the onset of arrhythmia, and only

in 17% arrhythmia can persist for a

longer period [2].

Relations between therapy and the

results obtained were analyzed using the

Cox’s regression model of proportional

intensities. In the 1st group of patients,

the analysis did not show statistically

significant correlations between therapy

and clinical parameters, between time of

relieving the AF paroxysm and the

administered antiarrhythmic

preparations (p = 0.2928 at a 8.91%

fraction of censored observations). In

the second group of patients, who

received acute care using

antiarrhythmics in combination with

diazepam, the analysis revealed a

statistically significant correlation

between these factors (p = 0.0068 at a

3.37% fraction of censored

observations). The obtained models are

described in Table 3, which shows that

the ultimate heartbeat rate in the 2nd

group is closely associated with the time

elapsed before the outcome under

consideration.

The assumption that antiarrhythmic

therapy and time of AF paroxysm relief

are not directly proportional to each

other was verified by analysis based on

the Cox’s model of proportional

intensities with time-dependent

covariates. As shown by the Chi-square

Test, there is a statistically significant

difference (Chi-square = 18.1783 at

p = 0.0001) between the models. The

model obtained in the 2nd group is

statistically significant (p = 0.0336) —

the time of AF paroxysm relief in this

group depends on the applied acute

therapy (antiarrhythmic preparations in

combination with diazepam).

Thus, the onset of AF paroxysm at pre-

hospital stage is accompanied by a

pronounced sympathicotonia. When

rendering acute care to AF patients at

pre-hospital stage, changes in the

vegetative tonus should be considered

and corrected. The combination of

diazepam with antiarrhythmic

preparations makes it possible to stop

the paroxysm promptly, often within the

first hour of the patient’s follow-up,

which prevents unnecessary

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 29

hospitalizations and improves the

patients’ quality of life. Since AF tends

to spontaneous restoration of the

rhythm in more than a half of patients

[2] and both the decrease in heartbeat

rate and the restoration of sinus rhythm

at atrial fibrillation equally improve the

patient’s status [5], it is clear that

antiarrhythmic therapy at pre-hospital

stage should be aimed mainly at

lowering the heart’s ventricular rate

rather than reducing the arrhythmia.

In our opinion, the currently accepted

tactics of mandatory hospitalization of

the patients with uncomplicated AF

episode that lasts up to 24 hours and is

not relieved at pre-hospital stage are not

quite correct. Such tactics increase the

number of unreasonable

hospitalizations and irrational use of

hospital resources, extend the work time

of medical emergency team and

decrease the team turnover rate, thus

increasing the wait time in acute care as

well as the delay time and unjustified

financial expenditures.

Conclusions

1. Irrespective of the underlying disease

and administered antiarrhythmic

preparations, the overwhelming

majority of atrial fibrillation cases are

relieved by the end of the first day after

beginning of the treatment.

2. The onset of atrial fibrillation

paroxysm at pre-hospital stage is

accompanied by a pronounced

sympathicotonia, which should be taken

into account during antiarrhythmic

therapy. The combination of diazepam

with antiarrhythmic preparations

provides a faster relief of the AF

paroxysm.

3. In the case of uncomplicated episodes

of atrial fibrillation lasting up to 24

hours, medical care tactics at pre-

hospital stage should be aimed primarily

at normalizing the heart’s ventricular

rate and vegetative imbalance.

4. In the case of primary appeal to acute

medical care, the tactics of mandatory

hospitalization of patients with

uncomplicated atrial fibrillation episode

that lasts up to 24 hours and is not

relieved by pre-hospital treatment are

invalid.

References

1. Vegetative Disorders: Clinical Picture,

Diagnostics and Treatment. Ed. Vein

AM. Moscow: Medical Information

Agency, 2003, 752 p.

2. Pogosova GV: Psychological stress and

acknowledgement of its value as a first

order cardiovascular risk factor.

Kardiologiya (Cardiology) 2, 65-72

(2007)

3. Popov SV, Batalov RE, Antonchenko IV:

Current aspects of atrial fibrillation

treatment. Bolezni Serdtsa I Sosudov

(Cardiovascular Diseases) 1, 30-34

(2009)

4. Prokhorovich EA, Talibov OB,

Topolyansky AV: Treatment of the

rhythm and conduction disturbances at

pre-hospital stage. Lechaschiy Vrach

(Hospital Doctor) 3, 56-60 (2002)

5. Guidelines for Acute Care Doctors. Eds.

Bagnenko SF, Vertkin AL,

Miroshnichenko AG, Khubutiya MSh.

Moscow: GEOTAR-Media, 91-99 (2009)

6. Skurikhina ON, Miller ON: Anxiety and

depression in patients with paroxysmal

and persistent atrial fibrillation. Vestnik

Aritmologii (Arrhythmology Bulletin)

55, 14-18 (2009)

7. Syrkin AL, Kopylov FYu, Popova EA et

al.: Mental disorders at different stages

of atrial fibrillation. Psikhicheskie

ISJM

30 Issue 01 / September 2013 isjm.kaznmu.kz

Rasstroistva v Obschei Meditsyne

(Mental Disorders in General Medicine)

2(4), 10-14 (2007)

8. Amar D, Zhang H, Miodownik S:

Competing autonomic mechanisms

precede the onset of postoperative atrial

fibrillation. J Am Coll Cardiol 42, 1262-

1268 (2003)

9. Bettoni M, Zimmermann M: Autonomic

tone variations before the onset of

paroxysmal atrial fibrillation,

Circulation 105, 2753-59 (2002)

10. Friberg J, Buch P, Scharling H et al.:

Rising rates of hospital admissions for

atrial fibrillation. Epidemiology 14, 666-

672 (2003)

Table I. Effect of antiarrhythmic therapy on the heartbeat rate, arterial pressure

level, respiratory rate and vegetative status of patients (M±σ)

Parameter Stage of

examination

1st group

(n = 903)

2nd group

(n = 106)

Mann-

WhitneyTes

t p1-2

HBR, min–1 before therapy 135.5±27.13 135.1±22.87 0.8104 after therapy 94.3±19.91 87.8±14.45 0.001

WilcoxonTest p1-2 <0.001 <0.001 − APsystol,

Mm Hg

before therapy 147.4±27.84 149.1±25.27 0.565 after therapy 133.4±15.47 131.4±16.01 0.146

WilcoxonTest p1-2 <0.001 <0.001 − APdiast,

Mm Hg

before therapy 89.6±13.76 90.3±12.81 0.830 after therapy 81.7±7.72 80.6±6.96 0.173

WilcoxonTest p1-2 <0.001 <0.001 −

RR, min–1 before therapy 17.4±2.78 17.2±2.07 0.565

after therapy 15.8±1.83 15.2±1.35 0.001 WilcoxonTest p1-2 <0.001 <0.001 − VI

(LQ-Me-UQ)

before therapy 22.2-33.3-42.7 23.1-32.0-42.8 0.782 after therapy 0.0-11.1-22.2 –3.6-4.7-19.5 0.013

WilcoxonTest p1-2 <0.001 <0.001 −

Q before therapy 7.9±1.84 7.9±1.33 0.947 after therapy 6.0±1.39 5.8±1.09 0.318

WilcoxonTest p1-2 <0.001 <0.001 −

MV (ml) before therapy 6518.5±1890.24 6587.7±1793.78 0.525 after therapy 4495.9±1200.66 4204.5±937.48 0.009

WilcoxonTest p1-2 < 0.0001 < 0.0001 −

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 31

Table II. Effect of antiarrhythmic therapy on the relief time of atrial fibrillation

paroxysm

Rhythm is restored Group up to 1 h

by 12th h

by 24th h

Mean time LQ-Me-UQ

1st group (n = 903) 189 736 875 2.0-6.0-10.0

% 20.9% 81.5% 96.9% − − 2nd group (n = 106) 43 94 102 1.0-2.0-7.0

% 40.6% 88.7% 96.2% − − Fisher's Exact Test (2-tailed P)

p1-2

0.0011 0.5986 0.9999 −

Cox's F-test p1-2 <0.0001

Table III. The Cox’s regression model of proportional intensities in the tested groups

of atrial fibrillation patients

Gro

up

1

n = 903

Chi-Square = 9.619; df = 8; p = 0.292

Beta

Standar

d

Error

t value

exponen

t

beta

Wald

Statist. p

HBR,

min–1

before

therapy 0.0031 0.0013 2.3515 1.0031 5.5299 0.0187

after therapy –

0.0039 0.0019

–

1.9729 0.9961 3.8927

0.048

5

APsysto

l,

mm

Hg

before

therapy

–

0.0018 0.0027

–

0.6861 0.9982 0.4707

0.492

6

after therapy 0.0014 0.0038 0.3676 1.0014 0.1352 0.7131

APdiast

,

mm

Hg

before

therapy 0.0058 0.0049 1.1699 1.0058 1.3688

0.242

0

after therapy –

0.0042 0.0068

–

0.6156 0.9958 0.3791 0.5381

RR, before 0.0032 0.0191 0.1659 1.0032 0.0275 0.868

ISJM

32 Issue 01 / September 2013 isjm.kaznmu.kz

min–1 therapy 2

after therapy 0.0106 0.0288 0.3686 1.0107 0.1359 0.7124

Gro

up

2

n = 106

Chi-Square = 21.122; df = 8; p = 0.006

Beta

Standar

d

Error

t value

exponen

t

beta

Wald

Statist. p

HBR,

min–1

before

therapy 0.0104 0.0048 2.1735 1.0104 4.7241

0.029

7

after therapy –

0.0357 0.0087 –4.1101 0.9649

16.892

6

0.000

0

APsysto

l,

mm

Hg

before

therapy

–

0.0034 0.0090

–

0.3721 0.9966 0.1384

0.709

8

after therapy 0.0079 0.0130 0.6077 1.0079 0.3693

0.543

4

APdiast

,

mm

Hg

before

therapy 0.0024 0.0142 0.1724 1.0024 0.0297 0.8631

after therapy –0.0171 0.0226

–

0.7603 0.9829 0.5781 0.4471

RR,

min–1

before

therapy

–

0.0057 0.0741

–

0.0765 0.9943 0.0059

0.939

0

after therapy –

0.0403 0.0981

–

0.4105 0.9605 0.1685 0.6814

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 33

INVESTIGATION OF STOMATITIS CAUSES AMONG THE STUDENTS AND DEVELOPMENT OF "PHYTOMEDICATION" FOR THE PREVENTION AND TREATMENT D. Sharipov E-mail: DShK1@mail.ru S.D. Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan

Actuality

In the Republic of Kazakhstan among the children aged from 6 months to 16 years who applied to the dental clinic, the cases of stomatitis 90%, with 80% of acute herpetic stomatitis. Therefore, the development of effective pharmacon for the prevention and treatment of stomatitis is an urgent.

The aim of this work

To investigate the causes of stomatitis among students and its influence on their attendance and performance, as well as to provide them an effective "Phytomedication" for the prevention and treatment, handy in using and in mobile formation.

Results

The results showed that the cause factor of stomatitis is various: mechanical trauma, infections, allergies, etc., but always stomatitis causes pain, discomfort and suffering. Also revealed that one of the common reasons for the development of stomatitis and recrudescence in adolescents feedings in the times of recreation, caused no personal hygiene, lack of capability to neutralize food particles and their degradation products, leading subsequently to pathological disorders of the gastrointestinal tract.

Designed composition comprises a substance derived from medicinal plants, which have a wide range of pharmacological effects, and applicatory no side effects. The compositions include extracts of chamomile flower, which has an antibacterial, anti-

inflammatory, soothing and recovering effect. Glycyram - water-soluble salt of monoammonium of glycyrrhizic acid, a derivative of licorice root which has an anti-inflammatory, antiviral activity and has a sweet taste, also serves as a flavoring component. An extract of oak bark, contains tannin, used as an astringent. Peppermint oil was introduced to impart a pleasant odor, as well as all essential oils have antiseptic activity. Rosehip extract and oil is used in the treatment of ulcers and fissures in the oral cavity, to promote healing.

At the laboratory of Santo, Member of Polpharma Group received extractive substance and extracts from plant material, select the rational structure of auxiliary substances and developed the technology of the "Phytostom" drug. The new pharmacon is designed in optimal dosage form for students: in granular form which packed in sachets and in the plates.

The main advantages of the granular formulation and plates are high bioavailability, rapid onset of therapeutic effect, portability, an accuracy of dosing, storage stability and the possibility of correction of unpleasant sensory properties of drugs.

Conclusion

In summary, as a result of the study:

- ostended the basic reasons for the development of stomatitis among students and its negative impact on their academic performance and attendance;

- derived biologically active substances from endemic medicinal plants;

ISJM

34 Issue 01 / September 2013 isjm.kaznmu.kz

- developed the technology of the new domestic pharmacon of oral using for the prevention and treatment of stomatitis (obtained the Innovation patent of the Republic of Kazakhstan for the drug "Phytostom» № 23948).

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 35

CHANGING OF SUCCINATE DEHYDROGENASE’S (SDH’S) ACTIVITY IN

HYPOTHYROIDISM OF NEWBORN AND PREGNANT WOMEN

Kulmaganbetov M.A.

E-mail: mukhit91@gmail.com

Scientific supervisor: d.m.s., prof. Pleshkova S.M., Department of biochemistry

S.D Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan

Actuality

Kazakhstan is a country in which the

problem of iodine deficiency is

extremely relevant. Iodine deficiency is

the reason of hypothyroidism - a serious

illness caused by the decrease in

functional activity of the thyroid gland.

Prenatal hormonal status’ correction of

pregnant reduces the risk of having

children with the disease and reduces

the impact of the disease to the

newborn. Syndrome (thyroid failure) is

formed in utero and manifested after

birth. This pathological condition may

be due to disembriogenesis (due to

anatomical defect producing the thyroid

gland, thyroid bud migration or fetal

injury) or due to functional immaturity

of enzyme systems involved in the

synthesis of hormones. Among the

reasons for its release of deficiency

iodine in the environment, the use of

supraphysiological doses of iodine in

pregnant women and infants, thyroid

disease the mother, adverse perinatal

factors. [1,2,3]

The purpose of the study

The study of the relationship between

SDH’s activity and levels of hormones

triiodothyronine (T3) and thyroid-

stimulating hormone (TSH) in pregnant

women and newborns.

Materials and methods

The object of the study was taken total of

40 pairs of "mother-child", 25 of who

had been diagnosed hypothyroidism -

the main group. The control group,

which was not detected hypothyroidism,

was 15 pairs of "mother-child

relationship." We studied the

concentration of TSH in newborns in the

peripheral blood.

Results

3-fold excess of TSH from the main

group as compared with the control

group represents increase of

hypothyroidism in the main group (table

1). During the 3 days the concentration

of TSH in the control group decreased

by 43%, which is normal for babies(table

1).

The enzyme SDH is a key enzyme of the

Krebs cycle, which represents activity of

the cell energy potential, so it is

important to consider its activity

(diagram 1).

ISJM

36 Issue 01 / September 2013 isjm.kaznmu.kz

The activity of SDH in the main group

below 15%, compared with the control

group, reflecting the decrease of redox

processes in the cells of pregnant

women and newborns with

hypothyroidism and pointed to the

development of their cellular hypoxia.

The analysis and conclusions

The study showed that the development

of hypothyroidism is accompanied by

decreased activity of SDH in the blood

leukocytes of newborns and mothers.

The direction of changes in the activity

of SDH in pregnant women and

newborns is the same, which allows

prenatally predict the development of

hypothyroidism.

We prove the relationship between

changes in the activity of SDH and the

concentration of thyroid hormones in

the blood of pregnant women and

newborns that allows us to judge about

diagnostic importance of SDH in the

diagnosis of hypothyroidism in pregnant

women.

Determination of SDH activity - one of the key enzymes of the Krebs cycle, confirms the data on the reduction of oxidative processes in the basic level of energy production, which leads to irreversible changes (disturbances in the differentiation and development of tissues and organs).

Table 1. Concentration of TSH in newborn’s peripheral blood (mME/l)

Time of blood

taking

Control group

(abs.)

General group

(abs.%)

Index

P

The 1st day of life 9,42±0,67 12,08±0,97(128) <0,001

The 2nd day of life 6,83±0,96 13,83±0,96 (202) <0,001

The 3rd day of life 5,35±0,55 16,35±0,55 (305) <0,001

Issue 02 / September 2013

isjm.kaznmu.kz Issue 02 / September 2013 37

Diagram 1. Activity of SDH in newborn’s blood

0

100

200

300

30 min 1st day 3rd day

The main group The control group

New rubric is for sharing

information about Health Care

System of countries. Here you can

find Country Profile, Brief History,

basic information about Health

Situation, Health Determinants,

Health issues and others.

The first trip will be to the Heart of

Eurasia – Kazakhstan! So, let’s get

started...

Kazakhstan is a country in Central Asia.

The 9th largest country in the world by land area

(territory of 2,727,300 square kilometres);

The world's largest landlocked country;

Capital is Astana, the largest city is Almaty

(former Alma Ata);

Population is 16,6 million (2011);

The climate is continental, with warm summers

and colder winters

The Kazakh ethnomedicine

An ancient ethnomedicine of Kazakhstan arose up on

the basis of practical experience of many generations. So,

for example, a hunt and stock-raising gave knowledge of

structure and functions of internal organs of animals, that

assisted knowledge of anatomy of man.

The Kazakh doctors gave a large value a prophylaxis

and timeliness of treatment. They systematized diseases in

two groups: external and internal. By the way, in the

Kazakh traditional medicine is much in common with the

methods applied by the Arab and Persian infirmarians.

Kamlaniye – the treatment, carried out dollars or the

healer, was accompanied, like a spiritualistic session,

calling of ancestral spirits by means of music, singing,

dances and rituals with fire. The essence of all these magic

rituals was reduced to one: the healer stole or tried to get

the soul selected at the patient at evil ghosts. The use of

musical instruments in treatment was explained by that

spirits that was used in a ritual flew on the sound of melody

of kobiz.

With arrival of islam on territory of ancient

Kazakhstan treatment began to be practiced with sanctified

stones, amulets, that was brought from Mecca.

Treatment by herbs on the basis of which there was a

traditional Kazakh medicine was one more direction of

ancient Kazakh medicine. Also after bathing of newborns

smeared with a fat tail, which has heated them.

In curative aims Kazakhs were use a kumiss until now

remaining excellent means at treatment of row of diseases.

Folk doctors could well treat a syphilis. For this aim

they prepared from different medical plants, roots and

arboreal bark strong infusion composition of that was kept

under a hat. Gave infusion two times in a day inside.

The most effective methods of treatment were different

surgical receptions.

The art of the Kazakh bone-setters is well-known.

Many researchers wrote about them. Bone-setters easily

and faultlessly could set any breaks of extremities, collar-

bones and even thighs, and also various arthral

dislocations. A tire was held to fixing of breaks, and it

depended on character of breaks and from age of man.

Currency is Tenge (1 USD = 157 Tenge);

The Kazakh, Russian & English languages;

Religious and language freedoms were

guaranteed by Kazakhstan’s Constitution;

Leader of KZ – president N.A. Nazarbaev

In Kazakhstan there are editions sanctified to history

and practice of the Kazakh ethnomedicine. The first books

were produced in soviet time. In a manual "Essays are on

history of ethnomedicine of Kazakhstan", going out in light

in 1978 edited by Toregeldy Sharmanov, it is talked that

Kazakhs "had necessary anatomic knowledge, a

comparative anatomy" was not bad developed.

Map of Kazakhstan Coat of Arms of KZ Flag of KZ

The history of our medicine is very cognitive. It is a

philosophy. Relationships of nature, people, animals, plants

are the basis of all. Everything is important - from the

physical cooperating with the surrounding world to the

manner of thoughts of man. Now we study diagnostics

methods, it too is interesting.. The Kazakh doctors

diagnosed, feeling a pulse. They paid attention to eyes.

“Salamatty Kazakhstan” State Program resultsfor 2012

The Government of Kazakhstan has been implementing the State Program of

Healthcare Development “Salamatty Kazakhstan” aimed at improving the people’s

health for ensuring the country’s stable socio-demographic development.

The main demographic indices following the results of 2012 per 1000 population are:

natural increase - 14.51; birth rate - 23.07; mortality - 8.56.

Upcoming events & Health Days

September-November 2013

2 September–30 October 2013 – Annual meetings of WHO

Regional Committees

23 September 2013 – UN High-level Meeting on Disability

and Development

24 – 29September 2013 – United Nations General Assembly

(UNGA)

6 – 11 October 2013 – 6th MIM Pan-African Malaria

Conference

17 – 18 October 2013 – UHC Annual Conference

20-26 October 2013 – International Lead Poisoning

Prevention Week of Action

30 October - 3 November 2013 – The 44th Union World

Conference on Lung Health

2 – 6 November 2013 – American Public Health Association

(APHA)

12 – 15 November 2013 – International Conference on Family

Planning

13 – 17 November 2013 – American Society for Tropical

Medicine and Hygiene (ASTMH)

S.D.Asfendiyarov Kazakh National Medical University

International Students Journal of Medicine (ISJM)

Issue 02 / September 2013

http://www.isjm.kaznmu.kz

Editorial Board is not responsible for the content of publications.

Authors of the works are responsible for the content of the articles.