Вопросы питания № 2 2022

Problems of Nutrition

scientific and practical journal

Included in the List of the leading peer-reviewed journals and publications recommended by the Higher Attestation Commission (HAC) of the Ministry of Education and Science of the Russian Federation for publication of the results of theses for the degree of candidate or doctor of science.


Content
2 . 2022
Diet treatment

Clinical aspects of the effectiveness of metformin therapy in combination with a low-calorie diet in patients with type 2 diabetes mellitus with various variants of the TCF7L2 gene polymorphism

Annotation

The TCF7L2 gene is one of the new markers associated with the development of type 2 diabetes mellitus (DM). Evaluation of the effect of TCF7L2 gene polymorphisms on the effectiveness of hypoglycemic therapy will allow an individual approach to the choice of methods for treating type 2 DM in their carriers.

The aim of the research was to study the effect of carriage of TCF7L2 gene polymorphisms on glycemic control parameters in patients with type 2 DM receiving metformin glucose-lowering therapy in combination with a low-calorie version of the standard diet.

Material and methods. The study included 55 patients with type 2 DM (mean age 59.9±6.9, BMI 44.3±8.2 kg/m2) receiving metformin monotherapy at a dosage of 1500–2000 mg/day in combination with a low-calorie variant of the standard diet (1730±130 kcal/day). The frequency of occurrence of polymorphisms rs7903146/rs12255372 of the TCF7L2 gene was studied. The indicators of glycemic and metabolic control, anthropometric parameters and body composition were evaluated.

Results. The frequency of occurrence of the T-allele of both single nucleotide polymorphisms rs7903146 and rs12255372 of the TCF7L2 gene among patients was 38.2%. Among carriers of the T-allele rs7903146 of the TCF7L2 gene, 72% of patients responded to therapy, showing a statistically significant decrease in the level of fasting glycemia by an average of 16.2±1.6% from the baseline, while among carriers of the CC genotype – 10.5±1.5% (p=0.017). There were no statistically significant changes in glycemic control indicators on hypoglycemic therapy during 7 months of observation, both in the group of T allele and CC genotype carriers.

Conclusions. An improvement in glycemic control was established in patients with type 2 DM among carriers of the T allele rs7903146 of the TCF7L2 gene during metformin therapy in combination with a low-calorie standard diet. The study of TCF7L2 gene polymorphism in combination with indicators of glucose metabolism makes it possible to predict the effectiveness of hypoglycemic therapy with great accuracy.

Assessment of the state of the small intestine microbiota in children on a long-term dairy-free diet

Annotation

An overview of recent outcomes of studies indicates an imbalance in the diet of children. Quantitative and qualitative malnutrition of children is the basis of a number of childhood diseases.

The aim of the research was to study the prevalence of small intestine bacterial overgrowth syndrome (SIBO) in children on a long-term dairy-free diet.

Material and methods. 40 children aged 7–11 years following a long-term dairy-free diet (average 3 years and 5 months, from 0.5 to 6.3 years) were examined (main group). 30 children who did not follow restrictive diets were consisted control group. In all children, SIBO was determined using a hydrogen breath test with a load of lactulose using a digital analyzer of exhaled hydrogen.

Results. The proportion of children with intolerance to dairy products was 32.5%: 10.0% with allergy to cow’s milk proteins, and 22.5% with lactose intolerance. 27.5% children followed a dairy-free diet according to an unjustified prescription by physician. 30.0% of children did not consume dairy products because of their unwillingness. 10.0% of children did not consume dairy products due to the unwillingness of their parents. An imbalance in the microbiota of the small intestine during the hydrogen breath test with lactulose loading was detected in 55.0% of children following a long-term dairy-free diet. 22.5% of children complained of recurrent abdominal pain, diarrhea was determined in 10.0%, constipation – in 7.5%, nausea – in 10.0%. In the control group, the SIBO during the hydrogen breath test with lactulose loading was found in 20.0%. Periodic abdominal pain was determined in 10.0%, nausea – in 6.7%, diarrhea – in 10.0%, constipation – in 3.3% children.

Conclusion. Thus, among children of primary school age who follow a long-term dairy-free diet, SIBO is significantly more often recorded relative to children who are on a traditional type of diet.

Should we prescribe low-protein diet for geriatric patient with chronic kidney disease?

Annotation

There are no clear dietary recommendations for patients over 70 years of age, while stages 3–5 of chronic kidney disease (CKD) and protein-energy wasting (PEW) is common among this category of patients. Nutritional status is known to be one of the significant factors influencing the prognosis of patients receiving renal replacement therapy.

The aim of the research was the analysis of the mechanisms of PEW, methods for assessing the nutritional status and effectiveness of diets with different protein content in patients with CKD based on literature data.

Material and methods. The research material was the scientific literature presented in the domestic and international (eLIBRARY, PubMed, Google Scholar) databases, as well as clinical recommendations for the management of geriatric patients with CKD, dietary recommendations for patients with anorexia and other conditions.

Results. The studies devoted to the mechanisms of PEW were analyzed. One of the leading causes of this condition is anorexia, in the pathogenesis of which uremic toxins, inflammation and hormonal disorders are involved (hormones such as gastrin, cholecystokinin, leptin, insulin, testosterone and others may be involved in the pathogenesis). A number of studies have shown that limiting protein to 0.6 g/kg day could significantly reduce uremic dyspepsia risk and slow CKD progression. At the same time, several researchers gave data on the ineffectiveness of a low-protein diet in patients with CKD and diabetes mellitus and a significant risk of malnutrition. Subjective global assessment, the mini nutrition assessment and the geriatric nutritional risk index can be distinguished among the methods of assessing nutritional status.

Conclusion. Research data on the effectiveness of a low-protein diet in elderly patients with stage 3B–5 CKD are contradictory. PEW in CKD is common and largely determines survival; the mechanism of PEW is complex. The study of the optimal nutritional diet for elderly patients with predialysis stages of CKD still remains an urgent problem.

Efficacy of newly developed food for special dietary use in the diet of patients with non-alcoholic steatohepatitis

Annotation

Although diet plays a leading role in treatment of non-alcoholic fatty disease (and, in particular, non-alcoholic steatohepatitis), specialized foods for the treatment of these patients have not yet been developed.

The aim of the study was to assess efficacy of the food for special dietary use (FSDU) in patients with non-alcoholic steatohepatitis.

Material and methods. New FSDU contained (% of the RDAs): protein – 8%; fat – 7% (including ω-3 PUFA – 40%); soluble dietary fiber – 180%; phospholipids – 25%; alpha-lipoic acid – 33%; betaine – 10%; 12 mineral substances – 13–44%; 13 vitamins – 24–140%. The study (NCT04308980) was approved by local ethics committee and enrolled patients with diagnosis of NASH. Subjects were randomized to the following groups: those received iso-calorie diet (according to resting energy expenditures, by indirect calorimetry) alone (ICD) and iso-calorie diet + FSDU (2 portions per day, 14 days) (ICD + FSDU group). Safety was assessed based on clinical and laboratory data. Repeated measurements (baseline vs those on the 15th day of the study) of body composition assessed by bioelectrical impedance analysis, and blood chemistry were compared.

Results. The results of complex examination of 20 subjects (12 in ICD + FSDU and 8 in ICD group) served as a source for the study. Initially, groups did not differ by age, sex, and body mass index (BMI). The product was well tolerated. In contrast to ICD group, those in ICD + FSDU group demonstrated greater decrease of weight: BMI initially (BMI0) (M±σ): 38.7±5.4 kg/m2 vs BMI at the end-point (BMIEOT) 36.7±5.1 kg/m2, p=0.003 in ICD + FSDU group, whereas in the ICD group BMI0=38.9±7.2 vs BMIEOT=38.9±7.3 kg/m2, p=0.08. These results were reached predominantly by a decrease of fat mass: body fat weight (BFW0) 50.2±10.7 vs BFWEOT=48.5±10.8 kg, p=0.002 in ICD + FSDU group, whereas BFW0=48.9±11.4 vs BFWEOT=47.8±11.6 kg, p=0.07 in ICD group. The activity of alanine and aspartate aminotransferase, gamma-glutamil transpeptidase and alkaline phosphatase decreased in ICD + FSDU group (р≤0.05), whereas in ICD group the difference between initial and control assessment was not significant (р≤0.10).

Conclusion. The new FSDU is well tolerated by patients with NASH. In combination with iso-calorie diet, it may increase efficacy of weight loss, predominantly by fat.

The role of polymorphic variants rs11546155 and rs6119534 of the GGT7 gene and risk factors in the development of acute pancreatitis

Annotation

Glutathione is an antioxidant with powerful restorative and detoxifying properties, a progressive decrease in its reserves in erythrocytes and pancreas observed in pancreatic necrosis indicates a lack of functioning of the system for maintaining the level of glutathione in cells and the use of its endogenous reserve. The study of the role of glutathione metabolism enzyme genes in the risk of acute pancreatitis in this regard is especially relevant.

The aim of the study was to evaluate the joint contribution of the rs11546155 and rs6119534 polymorphic loci of the GGT7 gene and some risk factors to the development of acute pancreatitis (AP).

Material and methods. Molecular genetic analysis of DNA samples of 506 unrelated patients with acute pancreatitis and 524 unrelated individuals of Russian nationality without gastrointestinal diseases, isolated by the standard method of phenol-chloroform extraction, was carried out. The average age of patients was 48.9±13.1 years, healthy persons – 47.8±12.1 years. The diagnosis was established using Clinical guidelines developed by the working group of the Russian Society of Surgeons. All patients signed informed consent to participate in the study. Genotyping was performed using iPLEX technology by time-of-flight mass spectrometry. Associations of gene alleles and genotypes with the risk of acute pancreatitis were assessed by the χ2 criterion and the odds ratio with 95% confidence intervals. Statistical analysis was performed using the SNPStats and Statistica 10.0 programs (Stat-Soft, USA).

Results. We have identified an association of the C/T (rs6119534) GGT7 genotype with an increased risk of AP, both in men and women. When analyzing the effect of polymorphic loci on the development of the polymorphic locus rs6119534 of the GGT7 C>T gene with an increased risk of developing acute alcoholic (AAlcP) and biliary pancreatitis (ABP), it was found that the C/T rs6119534 genotype of the GGT7 gene was more common both among patients with AAlcP and ABP, and the G/G GGT7 genotype (rs11546155) was found only among ABP patients. An analysis of the combined influence of polymorphic loci and environmental factors showed that the frequency of drinking alcohol more than 2 times a week and eating fat more than 89 grams per day increased the risk AAlcP in carriers of C/T-T/T rs6119534 of the GGT7 gene. As for ABP, non-smoking carriers of the G/A-A/A GGT7 (rs11546155) genotypes had a reduced risk of the disease, while the consumption of fats over 89 g/day and fresh vegetables and fruits below 27 g/day increased the risk in carriers of genotypes C/T-T/T and C/T rs6119534 of the GGT7 gene, respectively.

Conclusion. Polymorphic loci rs6119534 and rs11546155 of the GGT7 gene, when exposed to certain risk factors, increase the risk of acute pancreatitis.

Hygiene of nutrition

Can night eating syndrome and sleep quality have strong relations with quality of life in early adulthood?

Annotation

Sleeping disorders can impair sleeping efficiency and lead to eating disorders and night eating syndrome. Eating disorders and night eating syndrome can be considered as factors that reduce the quality of life.

The aim of the study was to investigate the effects of eating and sleeping disorders, and night eating syndrome, on quality of life.

Material and methods. The sample of the descriptive, cross-sectional research was comprised of 846 students, who were studying at Uskudar University in the 2020/2021 academic year, accepted to participate in the study and provided complete information. Data was collected with a diagnostic form, a SCOFF Eating Disorders Scale form, a Night Eating Questionnaire (NEQ) form, a Pittsburgh Sleep Quality Index (PSQI) form, and a World Health Organization Quality of Life Short Form (WHOQOL-BREF-TR) together, all were created in Google Forms and applied online. Research data was evaluated with IBM SPSS v26® software.

Results. A total of 846 university students, consisting of 712 (84.2%) females and 134 (15.8%) males participated in the study. The mean age of the participants was 21.4±3.1 years, and the mean body mass index was 22.5±8.0 kg/m2. Eating disorders risk was found as 38.4%, night eating syndrome risk as 67.7% and all participants had poor sleep quality. WHOQOL-BREF-TR scale’s total and all sub-dimension mean scores were found to be lower in students with a risk of eating disorders and night eating syndrome, compared to students without it (p<0.001). A statistically significant negative correlation was found between the PSQI total score and WHOQOL-BREF-TR scale’s total and all sub-dimension scores of the participants (p<0.001).

Conclusion. Students with a risk of night eating syndrome have interrupted sleep due to desire to eat at night, which is another factor that reduces sleep quality. For healthy generations, sleep and nutrition habits should be carefully examined and appropriate treatment methods should be applied by determining the faulty attitudes of individuals in nutrition, eating and sleeping disorders.

Vitaminology

Vitamin supply of patients with type 2 diabetes mellitus complicated by nephropathy

Annotation

Insufficient vitamin content in the diet is a risk factor for the development of various diseases and their progression, and drug therapy can also contribute to the development of a deficiency of these micronutrients. Data on vitamin sufficiency of patients with type 2 diabetes mellitus (T2DM) and diabetic nephropathy (DN) are needed to develop measures to improve it.

The aim of the research was to compare vitamin status of patients with T2DM without DN and those with T2DM complicated by nephropathy by assessing vitamin blood level and urinary excretion.

Material and methods. In a single-stage research, 57 patients with T2DM and concomitant obesity (14 men, 43 women aged 42–75 years) have been examined. The 1st group included 26 patients with T2DM (7 men and 19 women, BMI 41.5±1.7 kg/m2) with glycated hemoglobin (HbA1c) – 8.0±1.4%, blood serum glucose level 8.1±0.6 mmol/l, glomerular filtration rate (GFR) – 86.7±3.0 ml/min per 1.73 m2, microalbuminuria – 18.0±2.0 mg/day. The 2nd group included 31 patients with T2DM complicated by DN (7 men and 24 women, BMI 42.5±1.3 kg/m2), with an HbA1c level of 6.4±0.2%, blood serum glucose level 6.8±0.3 mmol/l, GFR – 62.8±2.7 ml/min per 1.73 m2, microalbuminuria – 59.5±22.5 mg/day. The determination of vitamins С (ascorbic acid), A (retinol), E (α- and γ-tocopherols), D [25(OH)D], B2 (riboflavin) and β-carotene in blood serum and vitamins C (ascorbic acid), B1 (thiamine), B2 (riboflavin) and B6 (4-pyridoxic acid) in the morning portion of urine collected on an empty stomach within 40–120 min was carried out. The vitamin status was assessed based on the concentration of vitamins in blood serum and urinary excretion relative to the lower limit of the norm, as well as using the criteria for the optimal supply and 2 molar ratios.

Results. Compared to patients with T2DM without nephropathy, patients with DN were better provided with vitamins B2, A and β-carotene: vitamin B2 deficiency was found 3.2 fold less often (in 9.7%), β-carotene – 1.8 fold less often (in 35.5%), non-optimal retinol level occurred twice less often (in 41.9%). At the same time, serum α-tocopherol level below the optimal level was found in 67.7% of individuals versus 50% among patients with T2DM without nephropathy, with a significantly reduced urinary excretion of vitamins B1 and B2. With the exception of one man, the rest of the DN patients had a deficiency or lack of vitamin D. The characteristic features of the vitamin status of patients in both groups were the complete absence of individuals who were simultaneously optimally provided with all the studied vitamins and β-carotene (when assessing the vitamin status using both the absolute serum vitamer levels and 2 additional molar ratios), and a high frequency of detection of several simultaneously non-optimal vitamin status indicators. A negative correlation was found between blood serum level of β-carotene and glycemia (ρ=-0.359, p=0.006), as well as GFR (ρ=-0.289, р=0.029) and positive with high-density lipoprotein cholesterol (ρ=0.423, р=0.001), that indicated the need to increase this antioxidant blood level in patients with T2DM. The presence of a negative correlation between the concentration ratio of vitamins C and E and glucosuria (ρ=-0.288, p=0.033) and postprandial glycemia (ρ=-0.313, p=0.031) indicated the need to maintain it at an optimal level.

Conclusion. For patients with T2DM and concomitant obesity, vitamin D and β-carotene turned out to be the most problematic, since their reduced levels are detected more often than other vitamins. In addition to the optimal blood level of vitamins C and E, it is extremely important for them to maintain the blood molar ratio of ascorbic acid and α-tocopherol at an optimal level. The purposefully development of specialized vitamin complexes containing effective doses is necessary for patients with DN.

Chemical composition of foodstuffs

Efficiency of an enzyme preparation obtained from a new mutant Bacillus subtilis-96 strain in the hydrolysis of whey and egg white proteins

Annotation

Whey and hen egg white proteins are characterized by high nutritional value, but possess antigenic properties, which limit their use in the production of dietary products. Enzymatic hydrolysis decreases significantly the allergenicity of proteins. The efficiency of hydrolysis depends on the specificity of the proteases used.

The aim of this work was to determine the effectiveness of EP-96 enzyme preparation obtained from Bacillus subtilis-96 culture liquid in the hydrolysis of whey and egg white proteins in comparison with commercial bacterial proteases preparations – Alcalase, Neutrase, and Protosubtilin.

Material and methods. Whey and egg white protein concentrates were used as substrates. Commercial enzyme preparations Alcalase, Neutrase, and Protosubtilin, and an experimental sample of EP-96 preparation obtained from Bacillus subtilis-96 culture liquid were used for hydrolysis. Hydrolysis was carried out at a substrate concentration of 100 g/L for 3 h at 55 °C or for 24 h at 50 °C. After hydrolysis, the reaction mixture was incubated at 90 °C for 15 min to inactivate the enzymes. The content of peptides with a molecular weight of less than 10 kDa was determined in the obtained hydrolysates. The hydrolysis of the main allergenic proteins was assessed by the disappearance of the corresponding protein bands on the hydrolysate supernatants electrophoregrams.

Results and discussion. All the studied preparations showed high efficiency in the hydrolysis of whey proteins and provided the yield of low molecular weight peptides at the level of 18.8–22.8% after 3 h of hydrolysis and 39.4–41.6% after 24 h. Sodium dodecyl sulfate polyacrylamide gel electrophoresis showed a residual amount of protein with a molecular weight of about 14 kDa, corresponding to α-lactoalbumin, after 3 h of hydrolysis when using Neutrase. The preparations containing serine protease, including EP-96, provided more intensive hydrolysis of whey proteins. In the hydrolysis of egg white protein, Neutrase showed the greatest efficiency. The efficiency of EP-96 was comparable to Neutrase both in the yield of low molecular weight peptides and in the intensity of cleavage of the main allergenic proteins. The effectiveness of preparations with predominant content of serine proteases – Alcalase and Protosubtilin was significantly lower.

Conclusion. The optimal ratio of neutral and serine proteases in the EP-96, obtained on the basis of the B. subtilis-96 strain, provided the high efficiency and its versatility in the hydrolysis of the main allergenic proteins of whey and egg white. The parameters of the hydrolysis technology using EP-96 are recommended, which provide intensive conversion of the main immunogenic proteins of whey and egg white to soluble and low molecular weight fractions (duration 3 h at a temperature of 55 °C and the proteolytic activity of the preparation is not less than 2 units per g of substrate) and an increase of subsequent ultrafiltration efficiency in the production of protein hydrolysates for foods for special dietary uses.

Methodological aspects of determining (estimating) the content of carbohydrates in juice products when placing information for consumers on packaging

Annotation

Information about the nutritional value included by the manufacturer in the labeling of consumer packaging of foodstuffs contributes to an informed choice in the formation of the diet and is extremely important for the consumer. This information is the subject of special attention both on the part of nutrition specialists and on the part of state control (supervision) bodies. At the same time, methodological approaches to determining (evaluating) the content of carbohydrates in juice products as an important component of its nutritional value require additional elaboration.

The aim of the work was to consider methods for determining (estimating) the content of carbohydrates in juice products and developing recommendations for their use.

Material and methods. Methodical approaches to determining (estimating) the content of carbohydrates in juice products for the purpose of labeling consumer packaging have been considered. Determination (assessment) of the content of carbohydrates in 85 samp- les of juice products was carried out using calculation and analytical methods and the analysis of the data obtained has been done.

Results. It has been established that the difference between the values of the carbohydrate content in juice products obtained by different methods can reach up to 20 percent. This is caused both by natural fluctuations in carbohydrate content in fruits and vegetables and, accordingly, in juices from them, and by the measurement uncertainty of the analytical methods used. The most accurate way to determine carbohydrates in juice products for consumer packaging labeling purposes is to measure and sum the content of individual sugars and sugar alcohols in the product. Next comes the calculation method based on data on the average content of sugars and sugar alcohols in industrial juices. Estimating the content of carbohydrates in a product by the determination of the content of soluble solids is the least accurate, while this method can be used with a sufficient degree of accuracy for juice products with a low juice content (10–20%).

Conclusion.
Methodological approaches have been developed to the choice of method for determining (estimating) the content of carbohydrates in order to label consumer packaging depending on the type of juice products. An analysis of the results obtained shows the need to specify the manufacturer’s procedure for determining (evaluating) carbohydrates in products for the purpose of labeling them in the technical regulation of the Customs Union TR CU 023/2011 «Technical regulation for juice products from fruits and vegetables», as well as establishing possible deviations from those indicated in the labeling values.

Brief reports

Formation of the organoleptic profile of sugar cookies with a modified fat component

Annotation

Currently, as part of solving the problems of improving the quality and safety of food, research is underway on the introduction of oleogels into foodstuffs to replace solid fats, which contain saturated and trans-isomeric fatty acids. However, such a replacement leads to a change in the organoleptic characteristics of food.

The aim of the work was to identify the characteristics that affect the difference in the perception of cookie descriptors baked using hard fat and oleogels.

Material and methods. Three batches of sugar cookies samples with different fat components were produced for the study: butter cookies; cookies based on oleogel structured with beeswax; and cookies based on oleogel structured with combinations of beeswax fractions. Organoleptic evaluation was carried out by two methods: the triangle method according to ISO 4120:2004 and the free-choice profiling method according to ISO 13299-2015. In this case, the profile was derived statistically, by means of a generalized Procrustes analysis.

Results and discussion. The analyze of cookies samples using the triangle method showed there was no noticeable difference between the control cookies samples and cookies with oleogel structured with beeswax, but there were significant differences with cookies baked with the use of oleogel structured with a combination of fractions. Generalized Procrustes analysis was used to interpret the results of the descriptor profile analysis. It was shown that differences in perception between samples were due to the severity of the following descriptors: Creamy flavour, Fat flavour, Floral flavour, Waxy flavour, Shape. A close correlation has been established between individual descriptors characterizing the samples under study.

Conclusion. The data obtained as a result of the conducted studies allow not only to judge the acceptability of the use of oleogels in cookies from an organoleptic point of view, but also to identify individual characteristics that affect the perception of cookie samples. In the future, this information can be used to optimize the formulation of finished cookies containing oleogels in order to change the organoleptic profile in a targeted manner.

Prediction of melting temperatures of wax gelators depending on their component composition

Annotation

The study of wax gelators is a new direction with the potential for use in foods for special dietary uses. Waxes of both plant and animal origin, which consist of various combinations of organic compounds: hydrocarbons, wax esters, free fatty acids and free higher alcohols, are among the studied ones. One of the main characteristics of these gelling agents is their melting point, which largely depends on the component composition of the wax. However, at present there are no models capable to reliably predict this parameter depending on the gel-forming agent composition.

The aim of this work was to build models predicting the influence of wax composition on its melting temperature.

Material and methods. Preparative flash chromatography was used to obtain individual fractions of the beeswax (obtained from a Russian apiary). On the basis of these fractions, combinations were made and their melting temperatures were measured using the method of differential scanning calorimetry. Two approaches were used to predict the melting temperatures of wax gel-formers: multiple linear regression and the construction of artificial neural networks.

Results. A total of 68 gelling agent combinations were analyzed. The model obtained on the basis of multiple linear regression was characterized by high values of the multiple correlation coefficient (r2=0.77). Nevertheless, high values of the standard deviation in the most cases led to false prediction results. The application of artificial neural networks made it possible to get a more reliable prognosticating system with high values of the correlation coefficient (r2=0.97) and the standard deviation not exceeding 3 °С.

Conclusion. As a result of the conducted work it has been shown that it is possible to predict melting temperatures on the basis of the component composition of gel-forming fractions. The use of the data obtained in the article will allow to develop oleogels with the specified composition and properties for their use in new types of foodstuffs.

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CHIEF EDITOR
CHIEF EDITOR
Viktor A. Tutelyan
Full Member of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Scientific Director of the Federal Research Centre of Nutrition, Biotechnology and Food Safety (Moscow, Russia)
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РОСМЕДОБР 2021
Вскрытие
Medicine today

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