Valerii V. Subbotin

Introduction . Secondary hemophagocytic lymphohistiocytosis (HLH) with refractory thrombocytopenia is a rare complication of acute myeloid leukemia (AML). Thrombocytopenia in HLH has a multifactorial origin, and immunosuppression and transfusions are often ineffective. Aim : to describe the use of selective IgG immunoadsorption as an adjunctive intervention for refractory thrombocytopenia in a patient with AML and secondary HLH. Main Findings: A 54-year-old woman with newly diagnosed NPM1-mutated AML, secondary HLH, antiphospholipid syndrome, and an insuffi cient post-transfusion platelet increment underwent four selective IgG immunoadsorption sessions using single-use IMMUNOCOR® VEGA columns. Platelet crossmatching was performed on a Galileo analyzer with Capture-P technology. Before immunoadsorption, platelet counts were (15–23)×10⁹/L. The corrected count increment (CCI) at 1 hour after transfusion was −1.75×10⁹/L on 28.01.2026 and +21.49×10⁹/L on 29.01.2026 after transfusion of a minimally reactive platelet unit (2+). All platelet units tested using Capture-P on 30.01.2026 and 02.02.2026 showed 3+ or 4+ reactivity; two of 19 platelet units tested on 02.02.2026 showed 1+ and 2+ reactivity, and four of fi ve platelet units tested on the 6th of February 2026 showed 1+ reactivity. No further platelet transfusions were required after the third immunoadsorption session, and the platelet count reached 268×10⁹/L at discharge on 18.02.2026. Selective IgG immunoadsorption may therefore be considered a promising adjunctive treatment for refractory thrombocytopenia associated with HLH and AML. The procedures were well tolerated in this case, but their independent contribution to platelet count recovery requires further study.

Introduction . The increasing number of laparoscopic surgeries necessitates the optimization of enhanced recovery protocols. Rapid emergence from general anesthesia is crucial for early patient mobilization. The elimination rate of inhalational anesthetics depends on cerebral blood flow, which is sensitive to arterial carbon dioxide tension (PaCO₂). The objective was to compare the emergence time using normocapnic versus hypercapnic mechanical ventilation during the emergence phase from general anesthesia in female patients undergoing laparoscopic hysterectomy. Materials and methods . This prospective single-center randomized trial included 64 female patients. After anesthesia induction, female patients were randomly assigned (envelope method) to either the normocapnic group (EtCO ₂ 36–43 mmHg, n = 30) or the hypercapnic group (EtCO₂ 51 ± 5 mmHg, n = 34) during sevoflurane washout. The primary endpoint was emergence time (from sevoflurane discontinuation to extubation). Secondary endpoints included blood pressure and heart rate variability during emergence, incidence of postoperative nausea and vomiting (PONV) at emergence and at 24 h and use of vasopressors/inotropes. No sample size calculation was performed (pilot study). Statistical analysis included the Mann–Whitney U test, binary logistic regression, and linear regression. All tests were two-sided, with a critical significance level of α = 0.05. Results . The median emergence time in the hypercapnic group was significantly shorter than in the control group: 6.8 [6.3–8.3] min vs. 10.6 [9.2–12.2] min ( p < 0.001). After adjustment for confounders, the ventilation strategy remained the only independent predictor of fast emergence (adjusted OR = 0.37; 95% CI 0.22–0.62; p < 0.001). Regression analysis revealed an inverse relationship: each 1% increase in EtCO₂ reduced emergence time by an average of 0.121 minutes (β = –0.121; 95% CI –0.166; –0.077; p < 0.001). The incidence of adverse events during emergence (hypertension, nausea, agitation) did not differ between groups. Conclusion . In this pilot study, the use of permissive hypercapnia (EtCO₂ 51 ± 5 mmHg) during the recovery phase from general anesthesia during laparoscopic hysterectomy was associated with a reduction in the time to awakening without an increase in the frequency of observed complications. These results are preliminary and require confirmation in studies with sufficient power.

Introduction . Alveolar proteinosis is a rare diffuse interstitial lung disease characterized by the accumulation of lipoproteins and phospholipids in the alveoli, which eventually leads to thickening of the alveolocapillary membrane, impaired oxygen diffusion, clinical manifestations and progression of respiratory failure, and, consequently, a decrease in the quality of life of patients. The disease was first described by S. H. Rosen et al. in 1958. The clinical picture is different, but the predominant complaint of the patient is shortness of breath and respiratory failure. Insufficient awareness of this disease among doctors leads to a later diagnosis and lack of quality care in accordance with the standards of the European Society for Respiratory Medicine. The objective was to demonstrate the clinical application of veno-venous extracorporeal membrane oxygenation (VV-ECMO) during total bronchoalveolar lavage in a patient with alveolar proteinosis. Results . The use of VV-ECMO in a patient with recurrent autoimmune pulmonary alveolar proteinosis with severe respiratory failure and total bilateral lung damage allowed for the safe performance of a total bronchoalveolar lavage procedure. The patient’s condition improved significantly, with an increase in arterial oxygen partial pressure from 38 to 72 mmHg, an increase in SpO₂ to 87% when breathing atmospheric air, and a significant improvement in exercise tolerance. Conclusion . The use of VV-ECMO allows for the safe performance of a total bronchoalveolar lavage procedure in a patient with total damage to both lungs due to pulmonary alveolar proteinosis.

The incidence of postmastectomy pain syndrome (PMPS) after mastectomy ranges from 20% to 60%. Interfascial blockade of the erector spinae muscle (ESPB) can reduce pain in early postoperative period after total mastectomy and possibly reduce the incidence of PMPS. Objective. To evaluate the effect of ESPB as a part of combined anesthesia on the incidence of PMPS after total mastectomy. Material and methods. A pilot prospective single-center randomized study included 88 patients divided into two groups: the study group — ESPB in addition to combined general anesthesia (CGA) (n=23), the control group (n=65) — CGA alone. Postoperative pain was assessed using the visual analogue scale (VAS) after awakening, 2 and 24 hours after surgery. The painDETECT questionnaire was used to estimate neuropathic component of pain 3 months later. Results. ESPB was followed by significantly lower VAS scores in 1, 2 and 24 hours after surgery, as well as lower PainDetect scores 3 months after surgery. The risk of postoperative PMPS was significantly lower in the study group by 10.7 (95% CI 1.3; 86.3) times. Conclusion. ESPB provides better early postoperative analgesia compared to standard intraoperative and postoperative analgesia. This approach significantly reduces the incidence of PMPS after total mastectomy by 10.7 (95% CI 1.3; 86.3) times.

The objective was to evaluate the effect of vibroacoustic pulmonary therapy (VAPT) on the dynamics of gas exchange parameters (PaO ₂ , PaCO ₂ , SpO ₂ , PaO2/FiO ₂ ratio and respiratory rate) compared with standard percussion drainage massage (PM) in patients with early postoperative respiratory failure after prolonged abdominal surgery. Materials and methods . A single-center prospective randomized study was conducted at Loginov Moscow Clinical Scientific Center in 2023–2025. Among 2,716 patients undergoing prolonged abdominal surgery (≥ 180 min from induction of anesthesia), postoperative respiratory failure was verified in 124 patients (4.6%). After stratified randomization according to surgical approach, patients were allocated to VAPT (n = 58) and PM (n = 66) groups. Arterial blood gases were assessed before treatment and 30 min after each of three sessions. Within-group dynamics were analyzed using the Friedman test with Durbin – Conover pairwise comparisons and Bonferroni correction (p < 0.008); between-group comparisons were performed using the Mann – Whitney U test (p < 0.05). Results . Baseline SpO ₂ , PaO ₂ and respiratory rate were comparable between groups (p > 0.05). In the VAPT group, baseline PaO ₂ /FiO ₂ was lower and PaCO ₂ was higher; this was considered when interpreting between-group differences. After three sessions in the VAPT group, PaO ₂ increased to 86.0 [84.0–94.0] mm Hg, PaCO ₂ decreased to 38.0 [36.0–39.0] mm Hg, PaO ₂ /FiO ₂ reached 404.0 [389.0–427.0], SpO ₂ reached 97.0 [96.0–97.0]%, and respiratory rate decreased to 16.0 [16.0–17.0] per min (p < 0.001 for within-group dynamics). In the PM group, changes were less pronounced: PaO ₂ reached 74.0 [72.0–90.0] mm Hg, PaCO ₂ stabilized at 44.0 [41.3–45.8] mm Hg, PaO2/FiO ₂ reached 343.0 [333.0–359.0], SpO ₂ reached 95.0 [94.0–95.0]%, and respiratory rate was 18.0 [17.0–18.0] per min. Post-treatment between-group differences were statistically significant for all evaluated parameters. Conclusion . In patients with early postoperative respiratory failure after prolonged abdominal surgery, inclusion of VAPT in the postoperative management program was associated with more pronounced improvement in oxygenation and ventilation compared with standard percussion massage. These findings allow VAPT to be considered a promising component of early respiratory rehabilitation; further studies with predefined clinical endpoints are needed to confirm its clinical effect.

INTRODUCTION: In recent years, large language models (LLMs) have found widespread application in healthcare. However, their effectiveness in solving specialized tests in Russian, particularly in anesthesiology and critical care, remains poorly studied. OBJECTIVE: To evaluate the performance of LLMs on single-answer multiple-choice questions in Russian anesthesiology and critical care, compared to results of resident physician teams from the "Professionals" competition at the Forum of Anaesthesiologists and Reanimatologists-2025. MATERIALS AND METHODS: We conducted a comparative study of responses to 30 test items from the qualifying stage of the "Professionals" competition. Results from 38 resident teams were compared against answers from LLMs: Generative Pre-trained Transformer (GPT)-4o, GPT-5, Alisa AI, DeepSeek V-3.2, GigaChat, Gemini 2.5 Flash, and Qwen3-Max. Comparison methods included rank analysis, pairwise comparison (win-rate), agreement assessment (Cohen's κ coefficient), and correlation analysis (φ-coefficient). RESULTS: The median score of participating teams was 24.5 out of 30, with one team achieving the maximum score (30/30). Four models (GPT-4o, GPT-5, DeepSeek V-3.2, Gemini 2.5 Flash) demonstrated 100 % accuracy (30 points), sharing first rank position with the leading team. These models achieved the 97th percentile, reflecting superiority over 37 of 38 participating teams. Qwen3-Max and Alisa AI scored 29.9 and 29 points respectively, ranking first and second in the overall rating (97th and 92nd percentiles). GigaChat provided no answers. The win-rate of LLMs against a randomly selected team varied from 0.97 to 1.00. Near-perfect agreement was observed among leading models (κ = 1.00), with very high correlation between their answers and the majority choice of residents (φ ≈ 1.00). No statistically significant differences were found between LLM results (p > 0.05). CONCLUSIONS: Modern large language models demonstrate high accuracy in solving standardized tests in anesthesiology and critical care in Russian, significantly exceeding the median performance of resident physician teams.

Objective. To demonstrate the challenges of selecting antihypertensive therapy in a patient with resistant arterial hypertension (AH) complicated by acute kidney injury (AKI) and renal replacement therapy (RRT), and to justify the choice of drug combination based on dialyzability. Clinical case description. A 66-year-old male patient was admitted for elective resection of a symptomatic suprarenal aortic aneurysm. In the preoperative period, AKI developed, requiring initiation of RRT. After surgical intervention (aneurysm resection with left renal artery grafting and balloon angioplasty of the superior mesenteric artery), the condition was complicated by stress-induced cardiomyopathy and pulmonary edema. AH became resistant. Antihypertensive drugs were selected considering pharmacokinetics and dialyzability. The final regimen (valsartan, carvedilol, modified-release nifedipine, torasemide) achieved target blood pressure (Conclusion. Management of resistant AH in patients with AKI and RRT requires an individualized approach based on the dialyzability of antihypertensive agents. The described combination may serve as an effective therapeutic option in similar clinical scenarios.

The aim of the research . Is to assess the frequency of postmastectomy pain syndrome in patients with breast cancer who underwent radical mastectomy at the Moscow Clinical Scientific Center n. a. A.S. Loginov of the Moscow Department of Health. Materials and methods . A retrospective, single-center, cohort study included 252 patients who underwent various modifications of radical mastectomy. Patients were surveyed after three months after surgery. Pain intensity was assessed using a Numerical Rating Scale (NRS 0-10), and the neuropathic component was identified using the painDETECT questionnaire. The obtained results were analyzed. The descriptive statistics of the data are presented in the format Me [Q1; Q3], where Me [Q1; Q3] represents the median and interquartile range. Results . PMPS was diagnosed in 78 patients (30.95%). The median pain intensity was 5,0 [4,0; 6,0] points. The pain was most often described as aching, less often bursting or burning, localized in the area of the postoperative wound and axillary region. The median score on the painDETECT neuropathic pain scale was 15 [7,0; 18,0] points. The syndrome developed after all types of mastectomies, but the groups were not comparable in size to establish a statistically significant relationship with the surgical technique. Conclusion . The study demonstrates that approximately one-third of patients (30,95%) develop postmastectomy pain syndrome after radical mastectomy, and its occurrence does not show a clear dependence on the specific modification of the surgical technique used. Clinically, this pain syndrome is characterized by predominantly moderate intensity and has a pronounced neuropathic component.

Diagnosis of cancer undeniably triggers significant stress in patients. Constant thoughts about upcoming treatments and fear of death increase anxiety inevitably. Consequently, this stress, intended as an adaptive mechanism, becomes distress associated with pathological reactions depleting the body. Clinical manifestations of stress may occur in perioperative period and complicate primary disease. Assessment of preoperative anxiety is important worldwide. However, none available method for identifying preoperative anxiety covers all predisposing factors and fears affecting psychological state. Objective. To identify specific anxiety factors concerning patients with their subsequent correction. Material and methods. The study enrolled 50 female breast cancer patients scheduled for mastectomy or breast resection. In the main group, patients underwent preoperative examination by anesthesiologist two weeks before surgery. The purpose of examination was to identify the main factors of anxiety according to original questionnaire for subsequent correction. In the control group, patients did not receive correction of anxiety factors. We analyzed anxiety levels considering salivary free cortisol and visual analogue scale. Results. According to univariate analysis, the main group was characterized by significantly lower VAS score of anxiety after conversation with anesthesiologist (6.4 [4.9; 7.6] vs. 1.8 [1.4; 3.3], p<0.001). Salivary cortisol two weeks before surgery (125.1 [88.9; 200.3] vs. 80 [55.3; 97.8]), immediately before surgery (116.1 [93.9; 206.2] vs. 95.1 [80; 119.4]), and three hours after surgery (129.7 [88.2; 230.4] vs. 82.7 [59.6; 105]) was significantly lower (p=0.002, p=0.007, p=0.007, respectively) in the main group. Conclusion. The questionnaire “Identification by anesthesiologist of the main preoperative anxiety factors” allows us to know the exact reasons of increased anxiety. Discussions addressing fears noted in the questionnaire reduce anxiety. This is confirmed by reduced number of fears upon re-surveying, VAS scores and free cortisol levels.

Muscle atrophy and metabolic disorders are serious clinical challenges that substantially worsen the prognosis and increase the mortality rates in critically ill patients. Despite being widespread, traditional nutritional support remains ineffective in intensive care units. Therefore, it is crucial to evaluate alternative pathophysiological mechanisms of muscle atrophy. This review of current publications identified anabolic resistance as a key factor reducing the effectiveness of standard nutritional support regimens for critically ill patients. In this condition, muscle tissue loses its ability to adequately respond to anabolic stimuli, such as amino acids or protein substrates. Pathophysiologically, anabolic resistance involves systemic inflammation, insulin resistance, immobilization, and bioenergetic muscle dysfunction. A stable isotope analysis revealed that anabolic resistance develops directly in muscle tissue rather than in the gastrointestinal tract. This explains why increasing protein intake alone is ineffective. Clinical studies have shown that critically ill patients reduce protein uptake into their skeletal muscles by 60% compared with healthy individuals. However, gastrointestinal absorption remains intact. In anabolic resistance, inflammation is a more important factor than insulin resistance. Intensive care unit–acquired weakness leads to long-term functional impairment and complicates patient rehabilitation. The analysis suggests that the current approaches to maintaining muscle mass in critically ill patients should be fundamentally revised. Instead of just increasing protein intake, new therapeutic strategies are needed to address intramuscular inflammation and impaired substrate utilization.