Carátula del artículo
Community-acquired pneumonia: the dynamics of senior medical students’ knowledge
Neumonía adquirida en la comunidad: la dinámica del conocimiento de los estudiantes de medicina senior
Anna A Gavrilova
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Roman A Bontsevich bontsevich@bsu.edu.ru
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Yana R Vovk
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Olga I Zemlyanskaya
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Valeria A Flusova
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Tatyana L Subina
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Vsevolod A Vinyukov
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Pavel A Galenko-Yaroshevsky
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Galina A Batischeva
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Konstantin M. Reznikov
Belgorod State University 85, Pobedy St., Belgorod, 308015, Russia, Rusia
Archivos Venezolanos de Farmacología y Terapéutica, vol. 39, no. 5, pp. 538-543, 2020
Sociedad Venezolana de Farmacología Clínica y Terapéutica
Received: June , 28, 2020
Accepted: July , 15, 2020
Published: September , 09, 2020
Introduction
Community-acquired pneumonia is an acute infectious and socially significant disease. The typical pathological feature of CAP is inflammation of the lower respiratory system, interstitium, and microvasculature, caused mainly by bacteria. However, viruses, fungi, and protozoa can also be an etiological factor.
In most cases, the severity of pneumonia depends on the following factors: the type of pathogen, the consistency of immune response, the morphological features of the inflammatory reaction, and the degree of damage of pulmonary tissue. Despite both the high level of knowledge of the disease pathogenesis and the appearance of new highly effective drugs and the improvement of prevention methods, CAP remains one of the most important socially significant infectious diseases among all population stratums and occupies one of the leading places in the mortality structure of infectious diseases. According to official statistics (Federal Research Institute for Health Organization and Informatics), 591.493 cases of CAP were registered in Russia in 2006, which totalized 4.14% including people over 18 years old (3.44%). The highest incidence of pneumonia among the adults was noted in the Siberian and North-Western Federal Districts (4.18% and 3.69%, respectively), the lowest – in the Central Federal District (3.07%). In 2017, 808.694 children under the age of five died from pneumonia, which is 15% of all children’s deaths around the world. The mortality of young and middle-aged people without concomitant diseases is more than 1-3%1. In the elderly, both in patients with concomitant diseases (malignant neoplasms, chronic obstructive pulmonary disease, diabetes, kidney and liver diseases, and cardiovascular system diseases) and in patients with severe CAP, the mortality rate reaches 15-30%2,3. Hence, the correct initial examination of the patient's severity condition and an immediate and rationally administered pharmacotherapy will contribute to both reducing the level of morbidity and mortality throughout the age groups and decreasing the enormous negative economic impact caused by acute respiratory diseases, including CAP4.
Therefore, it is extremely important to not only assess the level of basic knowledge of the future health care workers and to identify their "weak spots", but also to carry out the subsequent analysis and correct mistakes with a help of educational activities devoted to CAP patients management. The study aims to determine the dynamics of senior medical students’ knowledge in the diagnosis and treatment of CAP before and after educational activities.
Material and Methods
The survey was conducted within the KNOCAP multicenter research project (the full name of the project “The assessment of students' and physicians' knowledge of community-acquired pneumonia basics”). We have assessed the knowledge and preferences of doctors and 85 senior medical students from Belgorod National Research University majoring in Medicine by surveying them two times – before and after the conduction of educational activities. The first stage of the project was carried out in 2017-2018, the second one – in 2018-2019. Educational activities were held during the educational process (in particular, during the course of Clinical pharmacology).
The method of anonymous questioning was used in this study, for which an original questionnaire was developed based on actual clinical guidelines5-7. For the correct answer, the respondent was awarded 1 point, for the incorrect answer - 0. The average scores of each respondent, the average scores for individual questions, and the average scores for the entire questionnaire were evaluated. The average completeness rate for the correct, partially correct, and wrong answers was defined as the average level of response completeness (ARC), which is equivalent to the average level of correct answers. For questions that required a mandatory “written” response (questions No. 12 and 13), when none was provided, 0 points were assigned. All information on the questionnaire was entered into an electronic database and processed using the application programs Microsoft Excel, Statistica 10. The McNemar Chi-square test was used to compare the available data, with the help of which the statistical significance of the differences in indicators was assessed, the normality distribution of which was previously determined by using the Kolmogorov-Smirnov test. The statistical significance of the differences was recorded at the level of bilateral p<0.05.
This method of knowledge evaluation was specially developed for the "KNOCAP" project and cannot fully reflect the general level of education quality in the university8-11.
Results and Discussion
At the first stage, 85 medical students were interviewed. Then, after the course of clinical pharmacology and various therapeutic cycles, the same students were re-interviewed. The number of senior medical students in the second stage of the project was 83. The average level of knowledge on questionnaires before educational activities was 43.8%, after – 51.8%. The detailed analysis of individual questions is presented below.
А. The framework of etiology, diagnosis, and prevention of CAP
In the first question, the respondent had to choose the most common pathogen of CAP from the proposed answers. The etiology of CAP is directly related to normal microflora that colonizes the upper respiratory tract. Only a few microorganisms with an increased virulence can cause an inflammatory reaction when entering the lower respiratory tract. Streptococcus pneumonia is such a pathogen and can cause a characteristic inflammatory process in 30-50% of cases. Therefore, pneumococcus is the main causative agent of CAP. At the initial stage of the study, the correct answer was given by 30.6% of respondents, at the second stage – by 33.3% (McNemar χ2= 0.221, p=0.639), which is an insufficient level of knowledge in this matter. The main mistakes of respondents: 27.6% of respondents indicated another type of streptococcus (S. pyogenes, S. haemoliticus), 19.7% of students chose the genus of staphylococcus (S. aureus and others), 26.3% of students believed that atypical microorganisms most often cause CAP, and the remaining number of respondents (26.4%) chose viruses/fungi/Haemophilus influenza or Enterobacteriaceaeas as the answer.
In the next question, it was required to indicate the highly efficient methods of CAP prevention used to date. Among the proposed answers including tempering, homeopathic and immunomodulatory therapy, the only correct answer was "vaccination with pneumococcal and influenza vaccine". At the beginning of the study, the correct answer was received from 65.9% of respondents, and after educational activities – from 65.4% (McNemarχ2=0.018, p=0.895).
According to the authors of the study, the absence of difference can be due to, first, an ambiguous attitude of the respondents to vaccination (12%)8,9 and, secondly, the beliefs in tempering, immunomodulatory therapy. However, to date, there is only one evidentially based mean against pneumococcus and influenza virus, it is vaccination7,10.
The next question required to identify the main diagnostic sign of CAP when examining the patient. The correct answer is the syndrome of pulmonary consolidation. There are the following signs of the syndrome: peeling of the affected side when breathing and an increased tactile fremitus during palpation over the same area, dullness of percussion sound, by auscultation – weakening of vesicular breathing over the foci of consolidation, bronchi crackle or crepitation. If there is no consolidation syndrome, the radiological conclusion about pneumonia is unjustified, because a change in the pulmonary pattern without lung tissue infiltration may be a sign of another disease6,12. At the initial stage of the study, the correct answer was received from 47.1% of respondents, and at the end of the second stage – from 45.7%. The observed decrease in the frequency of incorrect answers was not statistically significant (McNemar χ2=0.011, p=0.916).
The diagnosis of a non-severe CAP is based on two examinations. Respondents were proposed to select from the following answers: single-plane radiography, biplane radiography, biochemical blood assay, general blood test, clinical analysis of sputum, microbiological analysis of sputum, and "Not sure". From the listed above, respondents had to choose a general blood test and biplane radiography [7,13]. At the initial stage of the study the correct answer was given by only 30.6% of medical students, and after educational activities – by 56.8%. The observed decrease in the frequency of incorrect answers after educational activities was statistically significant (McNemar χ2 =6.128, p <0.014).
The next question was – «What makes the diagnosis of pneumonia ‘inaccurate/uncertain’:
1. lack of temperature and white blood cells;
2. lack of x-ray examination;
3. the absence of pulmonary consolidation syndrome;
4. lack of cough, wheezing in the lungs.
The inaccessibility or absence of radiological confirmation of focal lung infiltration (fluorography or radiography) makes the diagnosis of pneumonia inaccurate/uncertain14,35.
Before educational activities, the correct answer was given by 29.4% of respondents, and after the training – by 55.6%, a visible increase in the number of correct answers is confirmed by the corresponding statistical analysis (McNemarχ2 =6, p=0.015).
If CAP treatment has positive dynamics, it is recommended to perform a repeated x-ray examination in 14 days or later15,16. At the initial stage of the study, 27.1% of students answered correctly, after educational activities the number increased to 45.7%. The observed increase in the frequency of correct answers was statistically significant (McNemarχ2 =4.057, p=0.05).
B. The basics of CAP pharmacotherapy
In the next question, it was necessary to indicate the possible reasons for delaying the onset of antimicrobial therapy (AMT). According to both the available clinical guidelines6 and the draft of new clinical guidelines7, there are no reasons for the delay of AMT with a confirmed diagnosis of CAP17,18. The initial level of correct answers totaled 64.7% and reached 69.1% at the second stage. Disregard of the increase, the observed decrease in the frequency of incorrect answers was not statistically significant (McNamar χ2 =0.455, p=0.501).
A stable normalization of body temperature over 48-72 hours, combined with both a positive clinical picture and the absence of signs of clinical instability, is a key criterion for terminating AMT for a non-severe CAP7,19. The level of correct answer before and after educational activities totaled 42.4% and 46.9%, respectively (McNemarχ2=0.391, p=0.532).
The next question was devoted to the question of "sequential therapy" for CAP. This type of therapy presumes two-stage administration of antimicrobial drugs: the use of parenteral form and the transition to oral form administration right after the stabilization of the patient's condition, normalization of body temperature, and the improvement of CAP clinical picture6,20,21. The initial level of the correct answer was 57.6% and increased to 67.9% after education activities were conducted. The observed increase in the frequency of correct answers was not statistically significant (McNemar χ2=1.613, p=0.205).
In the next question, it was necessary to indicate typical mistakes in the initial AMT for a non-severe CAP. The following antimicrobial drugs (AMD) options were offered to the respondent: ampicillin + oxacillin («Ampiox»), ciprofloxacin, cefazolin, ampicillin per os, respiratory fluoroquinolones in patients without risk factors. According to the clinical guidelines6,7, all options refer to an erroneous strategy in a non-severe CAP patients’ management22,23. Initially, only 2.4% of the respondents answered correctly, and after the educational activities were conducted, the level of correct answers grew up to 27.2% (Figure 1). The observed decrease in the frequency of incorrect answers was statistically significant (McNemarχ2= 35.438, p <0.001).
Figure 1
The dynamics of responses to the question about typical errors in an initial AMT for a nonsevere CAP
The other questions required a "written" response. In the first question, it was necessary to indicate the optimal starting therapy for a non-severe CAP in both patients with neither risk factors nor concomitant diseases (diabetes, chronic renal insufficiency, congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic alcoholism, cachexia, drug addiction, liver cirrhosis) and/or patients who had been taking systemic antimicrobial drugs (AMD) in the last 3 months for more than 2 days. Drugs of choice are amoxicillin or macrolides when suspected of "atypical" etiology of the disease (S. pneumoniae and M. рneumoniae)6,24. At the initial stage of the study the correct answer was received from only 3.5% of medical students, and after the conduction of educational activities, the rate increased to 39.5% (Figure 2). The observed decrease in the frequency of incorrect answers after educational activities was statistically significant (McNemarχ2 =11.796, p <0.001).
Figure 2.
The dynamics of responses to the question about an initial therapy for a non-severe CAP in patients with neither risk factors nor concomitant diseases
The following question required to indicate the optimal starting therapy for a non-severe CAP in both patients with either risk factors or concomitant diseases and/or patients who had been taking systemic AMD in the last 3 months for more than 2 days. It is recommended to prescribe tablets forms of AMD to such patients, but the therapy strategy in these patients is different because the probability of the etiological role of gram-negative flora increases6,25-27. Combined AMD could be used as initial therapy: amoxicillin + clavulanic acid, if “atypical” microflora is suspected a combination of β-lactam and macrolide may be prescribed28-30. An alternative to combined therapy is the administration of respiratory fluoroquinolones (levofloxacin, moxifloxacin, hemifloxacin)6,31,32 or, according to the draft of new clinical guidelines – oral cephalosporins (cefditoren)7,33,34,36. At the initial stage of the study, the correct answer was given by only 2.4% of medical students, and after the educational activities were conducted their number increased to 27.2% (Figure 3). The observed decrease in the frequency of incorrect answers after educational activities was statistically significant (McNemar χ2=4.056, p=0.045).
Figure 3
The dynamics of responses to the question about an initial therapy for a nonsevere CAP in patients with risk factors and concomitant diseases
Conclusion
The results of the study are ambiguous: on the one hand, there is a statistically significant increase in the level of knowledge as per individual questionnaire questions (mainly questions related to CAP pharmacotherapy), which indicates the value of educational activities. On the other hand, there are still some questions where the level of correct answers did not change after the conduction of educational activities. The lowest increase in the number of correct answers was noted in the following questions: highly efficient method of CAP prevention; the choice of both the main criterion for terminating AMT and the criterion confirming the diagnosis of CAP; the main diagnostic sign of CAP when examining the patient. According to the authors, an insufficient level of knowledge shown in the study is associated with the limited duration of educational activities during the curriculum. To cover the CAP patients’ management tactics in details it is recommended to increase the number of academic hours in the related disciplines: therapy, pulmonology, and clinical pharmacology. Moreover, it is necessary to emphasize that due to the healthcare system optimization, according to the authors, modern medical students experience the lack of hours devoted to practical lessons. This may be the reason for their incomplete knowledge of some fundamental issues of CAP patients’ management.
References
1. Spichak, T.V., 2019. Lechenie vnebol'nichnoy pnevmonii v ambulatornykh usloviyakh: uchimsya na oshibkakh. Medical soviet, 11: 172-178. (In Russian)
2. Rachina, S.A., Sinopal'nikov, A.I.,2018. Klinicheskie rekomendatsii po vnebol'nichnoy pnevmonii u vzroslykh: chtonaszhdet v 2019. Practical Pulmonology, 3:8-13. (In Russian)
3. Sinopal'nikov, A.I.,2019. Antibiotiki i vnebol'nichnye infektsii nizhnikh dykhatel'nykh putey. Komu Kakoy Clinical Microbiology and Antimicrobial Chemotherapy,1: 27-38. (In Russian)
4. Breitling, L.P., Saum, K.U., Schottker, B., Holleczek, B., Herth, F.J., Brenner, H.,2016. Pneumonia in the noninstitutionalized older population. DtschArztebl Int. 113:607–614.
5. Chernomortseva, E.S., Pokrovskiĭ, M.V., Pokrovskaia, T.G., Artiushkova, E.B., Gureev, V.V., 2009. Experimental study of cardioprotective and endothelioprotective action of macrolides and azalides. Experimental and Clinical Pharmacology. Eksperimental'naiai Klinicheskaia Farmakologiia, 72(2):29-31
6. Chuchalin, A.G., Sinkopalnikov, A.I., Strachunskiy, L.S., 2010. Community-acquired pneumonia in adults: practical recommendations for diagnosis, treatment and prevention. Klinicheskaya mikrobiologiya i antimikrobnaya khimioterapiya,12(3):186-225. (In Russian)
7. ProektklinicheskikhrekomendatsiyRossiyskogorespiratornogoobshchestvapovnebol'nichnoyterapii [Draft clinical guidelines of the Russian Respiratory Society for community-acquired pneumonia], 2018. 98. (In Russian)
8. Bontsevich, R.A., Filinichenko, T.S., Vovk, Y.R., Gavrilova, A.A., Prozorova, G.G., Goncharova, N.Y., Cherenkova, O.V., Kompaniets, O.G., Kirichenko, A.A., Ebzeeva, E.Y., Ketova, G.G., Barysheva, V.O., Myronenko, O.V., Milutina, E.V., Shagieva, T.M., Luchinina, E.V., Galkina, I.P., Nevzorova, V.A., Martynenko, I.M., 2019. Comparative assessment of physicians’ and senior medical students’ basic knowledge in treatment of chronic obstructive pulmonary disease. Research Results in Pharmacology, 5(1): 67–75.
9. Bontsevich, R.A., Gavrilova, A.A., Prozorova, G.G., Kompaniets, O.G., Ebzeeva, E. Yu., Krotkova, I.F., Mironenko, E.V., Luchinina, E.V., Shagieva, T.M., Barysheva, V.O., Ketova, G.G., Martynenko, I.M., Galkina, I.P., Maksimov, M.L., Osipova, O.A., Milyutina, E.V., 2019.Vnebol'nichnayapnevmoniya: otsenka bazovykh znaniy vrachey terapevticheskogo profilya. Tekushchie rezul'taty proekta KNOCAP [Community-acquired pneumonia: assessment of the physicians’ basic knowledge. KNOCAP current project results]. Farmateka, (11):44-47. (In Russian)
10. Bontsevich, R.A., Gavrilova, A.A., Prozorova, G.G., Myronenko, O.V., Shagieva, T.M., Kompaniets, O.G., Barysheva, V.O., Ketova, G.G., Luchinina, E.V., Miliutina, E.V., Filinichenko, T.S., Osipova, O.A.,2019. The assessment of physicians' knowledge of community-acquired pneumonia basics: KNOCAP study. European Respiratory Journal, 54 (63): PA1483.
11. Korokin, M.V., Soldatov, V.O., Tietze, A.A., Golubev, M.V., Belykh, A.E., Kubekina, M.V., Puchenkova, O.A., Denisyuk, T.A., Gureyev, V.V., Pokrovskaya, T.G., Gudyrev, O.S., Zhuchenko, M.A., Zatolokina, M.A., Pokrovskiy, M.V., 2019. 11-amino acid peptide imitating the structure of erythropoietin α-helix b improves endothelial function, but stimulates thrombosis in rats. Pharmacy & Pharmacology.;7(6):312-320.
12. Korokin, M., Gudyrev, O., Gureev, V., Korokina, L., Peresypkina, A., Pokrovskaia, T., Lazareva, G., Soldatov, V., Zatolokina, M., Pokrovskii, M., 2020. Studies to Elucidate the Effects of Furostanol Glycosides from Dioscoreadeltoidea Cell Culture in a Rat Model of Endothelial Dysfunction. Molecules, 25(1), 169.
13. Denisuk, T.A., Pokrovskii, M.V., Philippova, O.V., Dolzhikov, A.A., Pokrovskaia, T.G., Korokin, M.V., Gudyrev, O.S., Osipova, O.A., 2015. Endothelio- and cardioprotective effects of HMG-CoA reductase inhibitors under the condition of endotoxin-induced endothelial dysfunction, 6(5): 1542-1547
14. Stepenko, Y.V., Soldatov, V.O., Zatolokina, M.A., Mayorova, A.V., Sysuev, B.B., Demidenko, A.N., Ivahno, E.N., Sarycheva, M.V., Pokrovskiy, MV.,2019. Stimulation of reparation in a linear wound model in rats by bischofit gel. Pharmacy & Pharmacology, 7(1):42-52.
15. Bobyntsev, I.I., Kryukov, A.A., Belykh, A.E., Dudka, V.T., 2016. Effect of Delta Sleep-Inducing Peptide on Functional State of Hepatocytes in Rats During Restraint Stress. Bull ExpBiol Med, 160(4):421-424.
16. Peresypkina, A., Pazhinsky, A., Danilenko, L., Lugovskoy, S., Pokrovskii, M., Beskhmelnitsyna, E., Solovev, N., Pobeda, A., Korokin, M., Levkova, E., Gubareva, V., Korokina, L., Martynova, O., Soldatov, V., Pokrovskii, V., 2020. Retinoprotective Effect of 2-Ethyl-3-hydroxy-6-methylpyridine Nicotinate. Biology (Basel), 9(3): E45.
17. Peresypkina, A., Pazhinsky, A., Pokrovskii, M., Beskhmelnitsyna, E., Pobeda, A., Korokin, M.,2019. Correction of experimental retinal ischemia by l-isomer of ethylmethylhydroxypyridine malate. Antioxidants, 8(2).
18. Pokrovskii, M.V., Pokrovskaia, T.G., Gureev, V.V., Barsuk, A.A., Proskuriakova, E.V., Korokin, M.V., Gudyrev, O.S., Belous, A.S., Kochkarov, V.I., Danilenko, L.M., Levashova, O.V., Mal'tseva, N.V., Polianskaia, O.S., 2012. Correction of endothelial dysfunction by L-arginine under experimental pre-eclampsia conditions. Eksperimental'NayaiKlinicheskayaFarmakologiya. 75(2):14-16.
19. Peresypkina, A., Pazhinsky, A., Pokrovskii, M., Beskhmelnitsyna, E., Pobeda, A., Korokin, M., 2019. Correction of experimental retinal ischemia by l-isomer of ethylmethylhydroxypyridine malate. Antioxidants, 8(2).
20. Kochkarov, V.I., Molchanova, O.V., Pokrovskii, M.V., Pokrovskaia, T.G., Jakushev, V.I., Gudyrev, O.S., 2014. Cardio protective action of thioctic acid combined with rosuvastatin in the combined hypoestrogen and l-name-induced nitrogen oxide deficiency. Research Journal of Pharmaceutical, Biological and Chemical Sciences, 5(6): 1357-1360
21. Bontsevich, R.A., Gavrilova, A.A., Adonina, A.V., Vovk, Y.R., Goncharova, N.Y., Batisheva, G.A., Cherenkova, O.V., Myronenko, O.V., Luchinina, E.V., Barysheva, V.O., Ketova, G.G., Bochanova, E.N., Tilekeeva, U.M., Dauletbekov, N.D., 2020. Pharmacotherapy and other aspects of senior medical students’ knowledge in community-acquired pneumonia: the final results of the KNOCAP II project. Research Results in Pharmacology 6(1): 93-99.
22. Filippenko, N., Malorodova, T., Pokrovskaya, T., Batishchev, S., Balamutova, T., Lihodedova, V., Urozhevskaya, Z., 2017. Approaches to antibiotic therapy in patients with calculous pyelonephritis, undergoing in-patient treatment in the department of urology. Research Results in Pharmacology, 3(1):73-78.
23. Kamat, I.S., Ramachandran, V., Eswaran, H., Abers, M.S., Musher, D.M., 2018. Low procalcitonin, community-acquired pneumonia, and antibiotic therapy. Lancet Infect Dis, (18):496–497.
24. Barber, K.E., Bell, A.M., Wingler, MJ.B., Wagner, J.L., Stover, K.R., 2018. Omadacycline Enters the Ring: A New Antimicrobial Contender. Pharmacotherapy, 38(12):1194–1204.
25. Shulginova, A.A., Konoplya, A.I., Bystrova, N.A., 2018. Disorders of the immune status in patients with chronic cerebral ischemia; differentiated pharmacological correction. Research Results in Pharmacology, 4(2): 105-123.
26. Weinberger, M. 2019. Does a Diagnosis of Community-Acquired Pneumonia in a Child Always Require Antibiotics? JAMA Pediatr, 173(8):797.
27. Tsukanova, K.O., Fitilev, S.B., Vozzhaev, A.V., Shkrebneva, I.I., Klyuev, D.A., 2018. Analysis of changes in pharmacotherapy of stable angina over the five-year period at specialized out-patient level of medical care (pharmacoepidemiological study). Research Results in Pharmacology, 4(2):47-58.
28. Leshchenko, I.V., 2017. Vnebol'nichnayapnevmoniya u vzroslykh: vozmozhnostilecheniya v ambulatornykhusloviyakh 2017. Community-acquired pneumonia in adults: treatment options on an outpatient basis. MS, 18.
29. Avdeeva, N.V., Sidorova, S.A., Gudyrev, O.S., Osipova, O.A., Golubev, I.V., 2019. Mechanism of neuroprotective effect of mGluR4 agonists. Research Results in Pharmacology, 5(2): 43-47.
30. Batishcheva, G.A., Zhdanova, O.A., Nastausheva, T.L., Chernov, Y.N., 2019. Characteristics of adverse side effects of corticosteroid therapy in children with nephrotic syndrome and methods of pharmacological correction. Research Results in Pharmacology, 5(1): 37-43.
31. Pertseva, T.A., Avramenko, І.V., 2017. Features of laboratory indicators of severe community-acquired pneumonia. Medychniperspektyvy, 2.
32. Samorodskaya, N.A., Polischuk, L.V., Eliseeva, L.N., 2019. Complex assessment of blood pressure regulation system in hypertension patients. Research Results in Pharmacology, 5(3): 1-9.
33. Palikova, Y.A., Palikov, V.A., Dyachenko, I.A., 2019. Maximum tolerant dose and analgesic activity of PT1 peptide. Research Results in Pharmacology, 5(3): 37-42.
34. Kulikov, O.A., Ageev, V.P., Marochkina, E.E., Dolgacheva, I.S., Minayeva, O.V., Inchina, V.I., 2019. Efficacy of liposomal dosage forms and hyperosmolar salines in experimental pharmacotherapy of acute lung injury. Research Results in Pharmacology, 5(2): 23-41.
35. Alkhamaisah, S. I., Younes, K. M., Gaipov, A., & Aljofan, M. (2019). Development and validation of a simple and sensitive HPLC method for the determination of liquid form of therapeutic substances. Electronic Journal of General Medicine, 16(6).
36. Uz, B. Synchronous Hodgkin Lymphoma and Papillary Thyroid Carcinoma: The Importance of Positron Emission Tomography/Computed Tomography (PET/CT).
Notes
Author notes
bontsevich@bsu.edu.ru
