Critical Care and Intensive Care Medicine, Emergency Medicine, Transplantation
20
Scopus Publications
Scopus Publications
1597: PULMONARY COMPLICATIONS AFTER SOLID ORGAN TRANSPLANTATION Ravshan Ibadov, Sardor Ibragimov Critical Care Medicine, 2026 Introduction: Solid-organ transplantation (SOT) is considered the main treatment option for patients with end-stage organ failure. We aimed to evaluate the incidence, outcomes and identify the risk factors of pulmonary complications after SOT. Methods: A retrospective, observational, single-center study was conducted on 1635 adult patients after SOTs including 1511 kidney and 124 liver transplants. Data were collected from medical records at our hospital. The data included initial clinical information obtained during hospitalization for each patient, intraoperative course characteristics, and patient parameters after surgery, as well as pulmonary complications (pleural effusion, atelectasis, pulmonary edema, pneumonia and acute respiratory distress syndrome (ARDS)) and other clinical outcomes. Results: In liver transplant recipients, the incidence of pulmonary complications during the early postoperative period was 30%. The etiology of the pulmonary complications was pleural effusion in 62.1%, pneumonia in 8.1%, atelectasis in 4.8%, pulmonary edema in 6.4%, and ARDS in 12.9% patients. The identified perioperative risk factors were: elevated white blood cell count (OR=1.6 per 1×109/L; 95%CI: 1.1–2.3), increased neutrophil-to-lymphocyte ratio (OR=2.0 per unit; 95%CI: 1.1–3.8), decreased arterial oxygen tension (PaO2) (OR=0.9 per mm Hg; 95%CI: 0.9–1.1), and lower INR values (OR=0.004 per unit; 95%CI: 0.0–0.5). In adult kidney recipients, pulmonary complications were less frequent (20.5%) and mostly secondary to noninfectious reasons early after surgery, whereas late respiratory failure frequently was due to infectious causes. Risk factors were age over 40 years (OR=2.8; 95%CI: 1.1-7.5), development of post-transplant diabetes (OR=3.1; 95%CI 1.0-9.3), need for posttransplant dialysis (OR=5.1; 95%CI: 1.2-21.4), acute (OR=6.5; 95% CI: 2.0-20.8) and chronic kidney transplant rejection (OR=11.9; 95%CI: 4.0-15.4). Conclusions: Liver transplant recipients are more likely to develop early pulmonary complications. In contrast, kidney transplant recipients tend to have more frequent long-term pulmonary complications and are often associated with infections and comorbidities. The identified risk factors may help guide early detection and treatment strategies.
1398: NONINVASIVE MONITORING OF GRAFT OXYGENATION WITH NIRS-LIVER IN ICU AFTER LDLT Ravshan Ibadov, Sardor Ibragimov, Azimjon Usmonov Critical Care Medicine, 2026 Introduction: Living donor liver transplantation (LDLT) is associated with a high risk of early vascular complications, which requires effective tools for real-time graft monitoring. Liver near infrared spectroscopy (NIRS-liver) is a new non-invasive method that allows continuous assessment of regional hepatic oxygenation (LSrO2). Methods: A prospective observational study was conducted involving 124 adult patients who underwent LDLT. On admission to the intensive care unit, a NIRS device (NONIN SenSmart X-100) was used, the sensors were positioned over the graft area under ultrasound guidance. LSrO2 values were continuously recorded for 48 hours after surgery. Laboratory parameters (Hb, lactate, liver enzymes, coagulation profile) and ultrasound parameters (hepatic artery blood flow velocity, resistance index [RI]) were simultaneously monitored. Correlation between LSrO2 and clinical and laboratory parameters was assessed after 3, 12, 24 and 48 hours using Pearson and Spearman coefficients. Vascular complications were analyzed using descriptive statistics, χ2-test, odds ratio and ROC-analysis. Results: Vascular complications were observed in 21.8% of cases (n=27), predominantly arterial (12.9%), with the most common being early hepatic artery thrombosis (4.8%) and early stenosis (3.2%). A significant positive correlation was observed between LSrO2 and hemoglobin at all time points (r=0.507 at 24 h, p< 0.0001). Platelet count correlated with LSrO2 only at 48 h (r=0.401, p=0.0001). Hepatic artery blood flow velocity showed a strong association with LSrO2 at 24 h (r=0.328, p=0.002) and 48 h (r=0.248, p=0.023). RI correlated significantly at 3 h (r=0.350, p=0.001). Elevated lactate levels were inversely correlated with LSrO2 at 24 hours (r=–0.329, p=0.002). Other variables (ALT, GGT, albumin, INR) did not show a significant association. Conclusions: NIRS-liver provides reliable monitoring of liver graft oxygenation in real time. Significant correlations with hemoglobin, arterial blood flow, and lactate levels confirm its physiological validity. Integration of NIRS into postoperative monitoring protocols may improve early detection of graft perfusion deficits and vascular complications.
Risk Factors for Acute Respiratory Distress Syndrome in Patients after Living Donor Liver Transplant Р. А. Ибадов, Sardor Khamdamovich IBRAGIMOV Experimental and Clinical Transplantation, 2025 OBJECTIVES: Acute respiratory distress syndrome remains a serious multifactorial complication after liver transplant, characterized by high mortality. Key determinants and risk factors for acute respiratory distress syndrome remain incompletely understood. MATERIALS AND METHODS: We retrospectively investigated risk factors for acute respiratory distress syndrome in 124 patients after living donor liver transplant between January 2018 and March 2025. We analyzed preoperative clinical information, intraoperative course characteristics, and patient parameters on admission to the intensive care unit after surgery, as well as complications and outcomes. Acute respiratory distress syndrome was diagnosed in accordance with the Berlin definition as the presence of acute hypoxemia, bilateral pulmonary infiltrates on chest radiography consistent with pulmonary edema, and respiratory failure not fully explained by cardiac dysfunction or fluid overload. We conducted multivariate logistic regression analysis to differentiate risk factors. RESULTS: Among the 124 analyzed patients, 16 (12.9%) were diagnosed with acute respiratory distress syndrome, predominantly within the first 24 hours. Preoperative presence of hepatopulmonary syndrome (odds ratio 6.86; P < .001), intraoperative high total red blood cell transfusion volume (odds ratio 1.90; P = .011), postoperative elevated white blood cell count (odds ratio 1.56; P = .020), neutrophil-to-lymphocyte ratio (odds ratio 2.00; P = .03), decreased Pao2 (odds ratio 0.93; P = .010), lower international normalized ratio (odds ratio 0.004; P = .027), total bilirubin concentration (odds ratio 1.01; P = .030), and serum albumin level (odds ratio 1.12; P = .006) were risk factors. Patients also experienced significantly higher rates of early postoperative complications, systemic disorders, prolonged mechanical ventilation and hospitalization, and hospital mortality (25%; P < .001). CONCLUSIONS: Acute respiratory distress syndrome after living donor liver transplant was associated with hepato-pulmonary syndrome, intraoperative large-volume red blood cell transfusion, postoperative white blood cells, neutrophil-to-lymphocyte ratio, Pao2, international normalized ratio, albumin, and total bilirubin.
Exploring the utility of near-infrared spectroscopy in liver transplantation: insights and challenges Ravshan Ibadov, Konstantin Semash, Mirshavkat Akbarov, Timur Dzhanbekov, Oybek Omonov, Azimjon Usmonov, Sardor Ibragimov Clinical Transplantation and Research, 2025 Maintaining adequate tissue perfusion and oxygen delivery to the transplanted liver is critical for positive patient outcomes. Near-infrared spectroscopy (NIRS) has emerged as a promising tool for evaluating graft function in liver transplantation, particularly in assessing tissue perfusion. This review consolidates current knowledge regarding the application of NIRS in liver transplantation, highlighting its potential for noninvasive, continuous monitoring of liver perfusion and early detection of hemodynamic disturbances. Initial studies demonstrate the sensitivity of NIRS in evaluating liver oxygenation, with significant correlations observed between NIRS readings and biochemical markers of liver function. However, the effectiveness of NIRS can be influenced by factors such as subcutaneous fat thickness and patient positioning. Recent advancements also suggest that NIRS may assist in predicting graft fibrosis and other long-term complications. More extensive studies are required to establish standardized protocols and validate the clinical utility of NIRS in liver transplantation.
Efficacy of Targeted Hemodynamic and Fluid Therapy under Echocardiography Control in Mitral Valve Replacement: Improving Intraoperative and Early Postoperative Outcomes Р.А. Ибадов, С.Х. Ибрагимов, С.П. Эргашев Kardiologija V Belarusi, 2025 Цель. Изучить влияние целенаправленной гемодинамической и инфузионной терапии под эхокардиографическим (ЭхоКГ) контролем на интраоперационные и ранние послеоперационные результаты у пациентов, перенесших протезирование митрального клапана (ПМК). Материалы и методы. В исследовании проанализированы данные 146 пациентов с митральной недостаточностью (МН), которым было проведено ПМК. Пациенты были распределены на группы: стандартной гемодинамической терапии (группа сравнения, n=74), основанной на предполагаемом предоперационном дефиците объема циркулирующей крови (ОЦК), показателях артериального давления (АД), частоты сердечных сокращений (ЧСС), центрального венозного давления (ЦВД) и диуреза; целенаправленной терапии (основная группа, n=72), основанной на данных интраоперационной чреспищеводной ЭхоКГ (ЧПЭхоКГ) и послеоперационной трансторакальной ЭхоКГ. Группы исследования были репрезентативны и не отличались статистически по предоперационным данным клинического, лабораторного и инструментального обследования. Период исследования начинался с индукции общей анестезии и заканчивался после достижения гемодинамической стабильности. Клиническое выздоровление определялось как успешная экстубация, отсутствие поддержки вазопрессорами и стабильная доза инотропной поддержки в течение >8 часов или 72 часов после поступления в отделение интенсивной терапии. Впоследствии мониторинг вторичных конечных точек продолжался в течение всего пребывания в больнице. Результаты. Время анестезии сократилось с 255±15,6 до 223±12,9 минуты (р=0,02), а время искусственного кровообращения (ИК) – с 94,0±3,8 до 82,0±2,8 минуты (р<0,001). Трудности при отключении ИК отмечались у 48,6% пациентов в группе сравнения и у 19,4% – в основной группе (р<0,001). Объем инфузии до стабилизации гемодинамики был выше в группе сравнения – 950±38,4 мл против 1100±28,4 мл в основной группе (р=0,002). Инотропные препараты чаще применялись в группе сравнения: допамин использовался у 29,7% пациентов (р=0,021), норадреналин – у 24,3% (р=0,035). Время искусственной вентиляции легких в основной группе составило 7,33±0,52 часа против 13,0±0,7 часа в группе сравнения (р<0,001), а пребывание в реанимации – 1,1±0,2 против 1,8±0,2 часа (р=0,014). Длительность госпитализации составила 10,1±0,6 суток в основной группе и 13,0±0,9 суток в группе сравнения (р=0,008). Частота острой ишемии миокарда была ниже в основной группе – 2,8% против 12,2% в группе сравнения (р=0,026). Заключение. Использование ЭхоКГ в реальном времени для целенаправленной терапии периоперационных гемодинамических и волемических нарушений при ПМК позволяет снизить риски и повысить эффективность лечения пациентов с МН. Purpose. To study the effect of targeted hemodynamic and infusion therapy under echocardiographic (EchoCG) control on intraoperative and early postoperative outcomes in patients undergoing mitral valve replacement (MVR). Materials and methods. The study analyzed data from 146 patients with mitral regurgitation (MR) who underwent MVR. The patients were divided into the following groups: standard hemodynamic therapy (comparison group, n=74), based on the estimated preoperative BCC deficit, blood pressure (BP), heart rate (HR), central venous pressure (CVP), and diuresis; and targeted therapy (main group, n=72), based on intraoperative transesophageal EchoCG (TEE) and postoperative transthoracic EchoCG. The study groups were representative and did not differ statistically in preoperative clinical, laboratory, and instrumental examination data. The study period started with general anesthesia induction and ended upon reaching hemodynamic stability. Clinical recovery was defined as successful extubation, no vasopressor support, and stable inotropic support dose for >8 hours or 72 hours after admission to the intensive care unit. Subsequently, secondary endpoints monitoring continued throughout the whole hospital stay. Results. The anesthesia time decreased from 255±15.6 to 223±12.9 minutes (p=0.02), and the artificial circulation (AC) time decreased from 94.0±3.8 to 82.0±2.8 minutes (p<0.001). Difficulties in disconnecting AC were noted in 48.6% of patients in the comparison group and in 19.4% in the main group (p<0.001). The infusion volume before hemodynamic stabilization was higher in the comparison group with 950±38.4 ml versus 1100±28.4 ml in the main group (p=0.002). Inotropic drugs were used more often in the comparison group: dopamine was used in 29.7% of patients (p=0.021), norepinephrine was used in 24.3% (p=0.035). The duration of artificial ventilation in the main group was 7.33±0.52 hours versus 13.0±0.7 hours in the comparison group (p<0.001), and the stay in intensive care was 1.1±0.2 versus 1.8±0.2 hours (p=0.014). The duration of hospitalization was 10.1±0.6 days in the main group and 13.0±0.9 days in the comparison group (p=0.008). The incidence of acute myocardial ischemia was lower in the main group with 2.8% versus 12.2% in the comparison group (p=0.026). Conclusion. The use of real-time EchoCG for targeted therapy of perioperative hemodynamic and volume disorders in MVR allows reducing risks and increasing the effectiveness of MR patient’s treatment.
Erectile dysfunction and reproductive disorders in patients with chronic kidney disease S. S. Kariev, F. R. Nasirov, R. A. Ibadov, S. Kh. Ibragimov Transplantologiya the Russian Journal of Transplantation, 2025 Introduction. Erectile dysfunction (ED) and associated reproductive disorders (RD) are a significant medical and social problem, especially in patients with chronic kidney disease (CKD). In this category of patients, the frequency of erectile and reproductive disorders is significantly higher than in the general population, which negatively affects their quality of life and psychoemotional state.Objective. The purpose of this review is to systematize current data on the prevalence, pathogenetic mechanisms and consequences of ED in patients with CKD and in kidney transplant recipients, as well as to analyze the effect of kidney transplantation (KT) on the restoration of sexual and reproductive function.Material and methods. The review includes homeland and foreign studies mostly published in the recent 5 years, which have devoted to the assessment of erectile function in patients with CKD and after KT. Particular attention is paid to the use of standardized assessment methods, such as the International Index of Erectile Function (IIEF-5), as well as the analysis of data on hormonal background, psychoemotional and social aspects.Conclusion. ED is a common complication of CKD caused by vascular, hormonal and psychoemotional factors. Effective treatment requires an interdisciplinary approach taking into account the somatic and psychological state of the patient. KT improves sexual function, but in some patients ED persists due to immunosuppression and concomitant diseases. Further research is needed to optimize diagnostics, therapy and improve the quality of life of such patients.
Optimizing Mitral Valve Replacement Outcomes: The Role of Goal-Directed Hemodynamic and Fluid Therapy in the Perioperative Period Ravshan A. Ibadov, Sherzod M. Aliev, Sardor Kh. Ibragimov, Suhrob P. Ergashev Innovative Medicine of Kuban, 2025 Background: There is no doubt that hemodynamic monitoring plays a crucial role in cardiac surgery. Research is generally aimed to identify optimal strategies for maintaining hemodynamic stability, reducing complications, and minimizing recovery time after surgery.Objective: To study the effect of echocardiography-guided goal-directed hemodynamic and fluid therapy on perioperative outcomes of mitral valve replacement (MVR).Material and methods: We analyzed data from 146 patients with mitral regurgitation who underwent MVR. The patients were grouped by standard hemodynamic therapy (comparison group, n=74) and goal-directed therapy (main group, n=72). The study groups were representative, and preoperative clinical, laboratory, and imaging data did not differ significantly between the groups. The study period began with the induction of general anesthesia and ended with hemodynamic stabilization achieved. This point of clinical recovery was defined as the successful extubation and absence of vasoactive support; the dose of inotropes and/or vasopressors was either completely weaned off or remained unchanged for >8 hours.Results: The study groups differed in several key parameters. The anesthesia time decreased from 255 to 223 minutes (P=.02), and the cardiopulmonary bypass time from 94 to 82 minutes (P<.001). The volume of fluids until hemodynamic stabilization was achieved was higher in the comparison group (P=.002). Inotropes were used more often in the comparison group (P><.05). The mechanical ventilation time in the main group and the comparison group was 7.33 and 13 hours, respectively (P><.001); the intensive care unit length of stay was 1.1 and 1.8 hours (P=.014), respectively. The incidence of acute myocardial ischemia was lower in the main group (2.8% vs 12.2%, P=.026). Conclusions: Goal-directed hemodynamic and fluid therapy significantly improves MVR outcomes and reduces the risk of postoperative complications and long-term use of cardiovascular drugs.> <.001) . The volume of fluids until hemodynamic stabilization was achieved was higher in the comparison group (P=.002). Inotropes were used more often in the comparison group (P <.05) ). The mechanical ventilation time in the main group and the comparison group was 7.33 and 13 hours, respectively (P <.001) ; the intensive care unit length of stay was 1.1 and 1.8 hours (P=.014), respectively. The incidence of acute myocardial ischemia was lower in the main group (2.8% vs 12.2%, P=.026).Conclusions: Goal-directed hemodynamic and fluid therapy significantly improves MVR outcomes and reduces the risk of postoperative complications and long-term use of cardiovascular drugs.
analYSiS Of The PreValence anD rOle Of MalaDaPTiVe lefT VenTricular reMODelinG in The riSK Of earlY renal GrafT DYSfuncTiOn R. A. Ibadov, D. A. Chernov, S. Kh. Ibragimov, Z. U. Abdugafurov, Z. T. Matkarimov Vestnik Transplantologii I Iskusstvennykh Organov, 2025 Objective: to study the prevalence of maladaptive left ventricular remodeling (MLVR) among kidney transplant (KT) candidates and the role of MLVR in the development of early graft dysfunction (EGD). Materials and methods. The study is based on a retrospective analysis of treatment outcomes in 650 patients who underwent a living related KT. Transthoracic echocardiogram revealed different types of left ventricular (LV) remodeling, whose prevalence was studied in the context of influence on the general population and specific «renal» risk factors. Two patient groups were also identified: Group I had EGD (n = 82) and Group II had primary graft function (PGF) (n = 79). These groups were comparable in terms of demographics, clinical data, and laboratory results (p > 0.1). The relative risk of developing EGD was calculated depending on whether maladaptive remodeling was present. Results. Concentric LV hypertrophy (cLVH) was detected in 341 (52.46%), eccentric (eLVH) in 174 (26.77%) patients. Concentric remodeling (CR) and normal LV geometry were detected in 86 (13.23%) and 49 (7.54%) patients, respectively. MLVR (cLVH + eLVH) was more common in men (p = 0.003). Compared to patients in the pre-dialysis stage, the risk of developing MLVR was 5.6 times higher for dialysis therapy durations up to 1 year, 8 times higher for durations 1 to 2 years, and 4.5 times higher for durations greater than 2 years (p < 0.05). The likelihood of developing MLVR was 8-fold higher in those with a functioning arteriovenous fistula (p < 0.001). As diuresis decreased, the odds of developing MLVR increased 4 to 15.8 times (p < 0.001). Depending on the severity of their anemia, patients with anemia had 2.7–13.8 times the chances of developing MLVR compared to those without anemia (p < 0.05). According to comparative analysis, the EGD group had a high prevalence of MLVR (p = 0.01). MLVR raised the risk of developing EGD in the post-transplant period by 8.5 times for cLVH (p = 0.049) and 14.5 times for eLVH (p = 0.011). Conclusion. The presence of MLVR in a KT candidate indicates the severity of cardiovascular disease brought on by progression of chronic kidney disease, and can also be regarded as one of the risk factors for EGD.
Multimodal imaging of mediastinal tumors: Advantages of integrating the finding of computed tomography and magnetic resonance imaging epublican Specialized Scientific, Practical Medical Center of Surgery named after Academician V.Vakhidov, Tashkent, Otabek D. Eshonhodjaev, Nigora M. Djuraeva, Republican Specialized Scientific, Practical Medical Center of Surgery named after Academician V. Vakhidov, Tashkent, Ravshan A. Ibadov, Republican Specialized Scientific, Practical Medical Center of Surgery named after Academician V. Vakhidov, Tashkent, Sharif U. Rakhimiy, SURGEMED Clinic, Uzbekistan, Sardor Kh. Ibragimov, Republican Specialized Scientific, Practical Medical Center of Surgery named after Academician V. Vakhidov, Tashkent, Khanum V. Abdukhalimova, et al. Vestnik Sovremennoi Klinicheskoi Mediciny, 2025 Introduction. Mediastinal tumors represent a clinical and radiological challenge due to their morphological polymorphism and potential malignancy. The present study aims to comprehensively evaluate the diagnostic value of computed tomographic angiography and magnetic resonance imaging with Diffusion-Weighted Imaging in the preoperative stratification of mediastinal tumors. This aims to improve therapeutic algorithms and prognostic evaluation. Aim. The primary objective was to investigate the efficacy of different diagnostic methods and approaches for mediastinal tumors to inform surgical treatment tactics and improve clinical outcomes. Materials and Methods. Based on the analysis of computed tomographic angiography data, the sensitivity and specificity of the method in diagnosing malignant and benign mediastinal tumors were assessed. The overall sensitivity was found to be 79.5%, with maximum sensitivity for angiomas (100%) and minimum for Group C thymomas (68.7%). Receiver Operating Characteristic analysis confirmed the high accuracy of computed tomographic angiography in differentiating malignant and benign mediastinal tumors (Area Under the Curve=0.817 and Area Under the Curve=0.843; p<0.001). The diagnostic value of the method for benign tumors was 100% for cysts, neurinomas, teratomas, and lipomas. With respect to thymic carcinomas, the sensitivity and specificity of computed tomographic angiography were 68.7% and 69.6%, respectively. Results and Discussion. The analysis showed that the use of computed tomography and magnetic resonance imaging with contrast allowed for accurate assessment of tumor size and the extent of invasion into adjacent structures. Minimally invasive methods demonstrated less trauma and reduced hospitalization time for patients. In 85% of cases, endoscopic interventions led to successful tumor removal with minimal complications. Open surgeries were primarily utilized for large and invasive tumors requiring extended resection. Conclusions. Computed tomographic angiography has demonstrated high diagnostic value in assessing mediastinal tumors, providing effective differentiation between benign and malignant lesions. The method further aids in identifying the degree of invasion and structural features, thereby guiding surgical intervention tactics.
IMPACT OF KIDNEY TRANSPLANTATION ON ERECTILE FUNCTION AND REPRODUCTIVE HEALTH IN MEN WITH CHRONIC KIDNEY DISEASE S. S. Kariev, F. R. Nasyrov, Sh. Sh. Shavakhabov, S. Kh. Ibragimov, Z. T. Matkarimov, E. R. Ibadov Vestnik Transplantologii I Iskusstvennykh Organov, 2025 Objective : to evaluate the impact of kidney transplantation (KT) on erectile function and reproductive health in men with chronic kidney disease (CKD). Materials and methods . A prospective study was conducted involving 276 male patients (mean age 44.3 ± 5.8 years) with CKD who underwent KT from a living related donor. Erectile function was assessed using the International Index of Erectile Function (IIEF-5). Penile hemodynamics were evaluated by Doppler ultrasonography of the penile arteries, while hormonal status was determined by measuring serum testosterone, luteinizing hormone, and follicle-stimulating hormone (FSH) levels. Reproductive function was assessed by semen analysis and testicular volume measurements at five time points: baseline, at high azotemia, and at 3, 6, and 12 months post-transplantation. Management of post-transplant erectile dysfunction included phosphodiesterase type 5 inhibitors (IIEF-5, 5 mg daily for 3 months, followed by 20 mg on demand), pelvic fl oor muscle exercises, vacuum therapy, and physiotherapy. Results . After 12 months of follow-up, erectile function was fully restored in 65.6% of patients. The proportion of moderate-to-mild erectile dysfunction decreased to 9.4%, while mild dysfunction persisted in 25% of patients, primarily due to residual vascular, hormonal, and psychoemotional factors. The mean IIEF-5 score increased signifi cantly from 13.2 ± 0.1 to 21.2 ± 0.2 (p < 0.001). The average peak systolic velocity in the right cavernous artery rose from 5.6 ± 0.1 cm/s to 7.2 ± 0.1 cm/s (p < 0.001). Serum testosterone levels increased from 4.6 ± 0.1 ng/ml to 5.6 ± 0.2 ng/ml (p < 0.001), and the proportion of patients with normospermia grew from 37.3% to 61.2% (p < 0.001). Erectile dysfunction persisted in 34.4% of patients despite therapy. Conclusion . The findings demonstrate a significant restoration of erectile function and fertility in most patients following KT and supported by comprehensive management of residual vascular, hormonal, and psychoemotional disorders.