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<article article-type="research-article" dtd-version="1.2" xml:lang="ru" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"><front><journal-meta><journal-id journal-id-type="issn">2658-6533</journal-id><journal-title-group><journal-title>Научные результаты биомедицинских исследований</journal-title></journal-title-group><issn pub-type="epub">2658-6533</issn></journal-meta><article-meta><article-id pub-id-type="doi">10.18413/2658-6533-2025-11-3-0-6</article-id><article-id pub-id-type="publisher-id">3852</article-id><article-categories><subj-group subj-group-type="heading"><subject>Фармакология, клиническая фармакология</subject></subj-group></article-categories><title-group><article-title>&lt;strong&gt;Изучение эффектов фонтурацетама на модели хронического непредсказуемого умеренного стресса (CUMS) у крыс&lt;/strong&gt;</article-title><trans-title-group xml:lang="en"><trans-title>&lt;strong&gt;Evaluation of the therapeutic effects of fonturacetam in the chronic unpredictable mild stress (CUMS) model in rats&lt;/strong&gt;&lt;br /&gt;
&amp;nbsp;</trans-title></trans-title-group></title-group><contrib-group><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Арутюнян</surname><given-names>Сона Смбатовна</given-names></name><name xml:lang="en"><surname>Arutyunyan</surname><given-names>Sona S.</given-names></name></name-alternatives><email>ss.arutyunyan.bio@gmail.com</email></contrib><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Шекунова</surname><given-names>Елена Васильевна</given-names></name><name xml:lang="en"><surname>Shekunova</surname><given-names>Elena V.</given-names></name></name-alternatives><email>shekunova@gmail.com</email></contrib><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Фаустова</surname><given-names>Наталья Михайловна</given-names></name><name xml:lang="en"><surname>Faustova</surname><given-names>Natalia M.</given-names></name></name-alternatives><email>faustova.nm@xn--dolinika-gch.ru</email></contrib><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Кашкин</surname><given-names>Владимир Александрович</given-names></name><name xml:lang="en"><surname>Kashkin</surname><given-names>Vladimir A.</given-names></name></name-alternatives><email>kashkinv@gmail.com</email></contrib><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Макарова</surname><given-names>Марина Николаевна</given-names></name><name xml:lang="en"><surname>Makarova</surname><given-names>Marina N.</given-names></name></name-alternatives><email>makarova.mn@doclinika.ru</email></contrib><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Макаров</surname><given-names>Валерий Геннадьевич</given-names></name><name xml:lang="en"><surname>Makarov</surname><given-names>Valery G.</given-names></name></name-alternatives><email>makarov.vg@doclinika.ru</email></contrib><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Фазылов</surname><given-names>Марат Феликсович</given-names></name><name xml:lang="en"><surname>Fazylov</surname><given-names>Marat F.</given-names></name></name-alternatives><email>maratfazylov@gmail.com</email></contrib><contrib contrib-type="author"><name-alternatives><name xml:lang="ru"><surname>Балабаньян</surname><given-names>Вадим Юрьевич</given-names></name><name xml:lang="en"><surname>Balabanyan</surname><given-names>Vadim Yu.</given-names></name></name-alternatives><email>bal.pharm@mail.ru</email></contrib></contrib-group><pub-date pub-type="epub"><year>2025</year></pub-date><volume>11</volume><issue>3</issue><fpage>0</fpage><lpage>0</lpage><self-uri content-type="pdf" xlink:href="/media/medicine/2025/3/Биомедисследования_3-97-120.pdf" /><abstract xml:lang="ru"><p>Актуальность: Хронический стресс может приводить к таким неблагоприятным последствиям как развитие синдрома профессионального выгорания (СПВ). Учитывая социальную значимость заболевания и отсутствие общепринятых схем лечения, поиск средств терапии СПВ является актуальной задачей. Схожесть этиологии СПВ (хронический стресс), а также некоторых биохимических, поведенческих и когнитивных изменений у человека с СПВ и у животных с моделируемым стрессом делает возможным использование экспериментальных моделей стресса для изучения некоторых аспектов СПВ и оценки терапевтической эффективности препаратов. Цель исследования: Изучить терапевтическую эффективность препарата МНН: фонтурацетам (ООО &amp;laquo;Гелеспон&amp;raquo;, Россия) на модели хронического непредсказуемого умеренного стресса (Chronic unpredictable mild stress, CUMS) у крыс для получения экспериментальных доказательств целесообразности применения препарата у пациентов с СПВ. Материалы и методы: CUMS моделировали на самцах крыс Wistar путем предъявления семи чередующихся стрессовых стимулов в течение 21 дня. Фонтурацетам (10 мг/кг, 30 мг/кг, 100 мг/кг) и препарат сравнения мезокарб (5 мг/кг) вводили внутрижелудочно на фоне моделируемого стресса ежедневно в течение 28 дней. В эксперимент были включены две контрольные группы: &amp;laquo;интактные&amp;raquo; нестрессированные крысы и крысы, подвергшиеся стрессу. Обе контрольные группы получали плацебо. Результаты: Терапия фонтурацетамом в дозах 10 мг/кг и 30 мг/кг улучшала процессы обучения и памяти стрессированных крыс в тесте &amp;laquo;Распознавание нового объекта&amp;raquo;. У этих животных не наблюдалось поведенческих изменений, характеризующих развитие тревожного поведения (тест &amp;laquo;Приподнятый крестообразный лабиринт&amp;raquo;). В тесте Порсолта стрессированные крысы, получавшие фонтурацетам, демонстрировали стратегию поведения, которая характеризовалась высоким уровнем активного поведения. Фонтурацетам препятствовал повышению концентрации кортикостерона и кортизола в крови стрессированных крыс. Мезокарб в дозе 5 мг/кг оказал сопоставимый терапевтический эффект, за исключением влияния на когнитивные функции. Заключение: По совокупности полученных результатов наибольший фармакологический эффект в отношении коррекции нарушений, индуцированных хроническим стрессом у крыс, оказал фонтурацетам в дозах 10 мг/кг и 30 мг/кг. Полученные результаты позволяют рассматривать фонтурацетам как лекарственный препарат, снижающий выраженность поведенческих, нейроэндокринных и когнитивных нарушений, которые возникают на фоне хронического стресса и/или СПВ</p></abstract><trans-abstract xml:lang="en"><p>Background: Chronic stress can lead to adverse consequences such as occupational burnout syndrome (OB). Considering the social significance of the disease and the lack of standard treatment, the development of pharmaceuticals for medical treatment of burnout is an urgent need. The similarity of the etiology of OB (chronic stress), as well as some biochemical, behavioral and cognitive changes in humans with OB and in stressed animals, makes it possible to use experimental stress models to study some aspects of OB and evaluate the effects of pharmaceuticals. The aim of the study: To study the therapeutic effectiveness of phenylpiracetam (INN:&amp;nbsp;fonturacetam) (Gelespon, Russia) using the chronic unpredictable mild stress (CUMS) model in rats to obtain experimental evidence of the feasibility of using the phenylpiracetam in patients with OB. Materials and methods: The CUMS model was developed using male Wistar rats, which were exposed to seven alternating stress stimuli over a period of 21 days. Fonturacetam (10 mg/kg, 30 mg/kg, 100 mg/kg) and the comparison drug mesocarb (5 mg/kg) were administered intragastrically against a background of simulated stress daily for 28 days. Two control groups were included in the experiment: &amp;ldquo;intact&amp;rdquo; unstressed rats and rats exposed to stress. Both control groups were treated with placebo. Results: Therapy with fonturacetam at doses of 10 mg/kg and 30 mg/kg improved learning and memory processes of stressed rats in the New Object Recognition Test. These animals did not exhibit behavioral signs of anxious behavior (Elevated Plus Maze Test). Porsolt test results showed that stressed rats treated with fonturacetam demonstrated a behavioral strategy that was characterized by a high level of active behavior. Fonturacetam prevented the increase of corticosterone and cortisol concentrations in the blood of stressed rats. Mesocarb at a dose of 5 mg/kg had a comparable therapeutic effect except for the effect on cognitive function. Conclusion: In sum, fonturacetam in doses of 10 mg/kg and 30 mg/kg exerted the most pronounced therapeutical effect on stress-induced changes in rats. The results obtained allow to consider fonturacetam as a pharmaceutical reducing the severity of behavioral, neuroendocrine and cognitive disorders that occur against the background of chronic stress and/or OB</p></trans-abstract><kwd-group xml:lang="ru"><kwd>хронический непредсказуемый умеренный стресс</kwd><kwd>синдром профессионального выгорания</kwd><kwd>депрессия</kwd><kwd>экспериментальные модели</kwd><kwd>фонтурацетам</kwd></kwd-group><kwd-group xml:lang="en"><kwd>chronic unpredictable mild stress</kwd><kwd>occupational burnout</kwd><kwd>depression</kwd><kwd>experimental models</kwd><kwd>fonturacetam</kwd></kwd-group></article-meta></front><back><ref-list><title>Список литературы</title><ref id="B1"><mixed-citation>Mariotti A. The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future Science OA. 2015;1(3):FSO23. DOI: https://doi.org/10.4155/fso.15.21</mixed-citation></ref><ref id="B2"><mixed-citation>ICD-11 [Электронный ресурс]. World Health Organization. International Classification of Desease 11th Revision. The global standard for diagnostic health information [дата обращения: 24.04.2024]. URL: https://icd.who.int/browse/2024-01/mms/en#129180281</mixed-citation></ref><ref id="B3"><mixed-citation>Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-11. DOI: https://doi.org/10.1002/wps.20311</mixed-citation></ref><ref id="B4"><mixed-citation>Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annual Review of Psychology. 2001;52:397-422. DOI: https://doi.org/10.1146/annurev.psych.52.1.397</mixed-citation></ref><ref id="B5"><mixed-citation>Jonsdottir IH, Sj&amp;ouml;rs Dahlman A. MECHANISMS IN ENDOCRINOLOGY: Endocrine and immunological aspects of burnout: a narrative review. European Journal of Endocrinology. 2019;180(3):R147-R158. DOI: https://doi.org/10.1530/EJE-18-0741</mixed-citation></ref><ref id="B6"><mixed-citation>Ed&amp;uacute;-Valsania S, Lagu&amp;iacute;a A, Moriano JA. Burnout: A Review of Theory and Measurement. International Journal of Environmental Research and Public Health. 2022;19(3):1780. DOI: https://doi.org/10.3390/ijerph19031780</mixed-citation></ref><ref id="B7"><mixed-citation>Jonsdottir IH, Nordlund A, Ellbin S, et al. Cognitive impairment in patients with stress-related exhaustion. Stress. 2013;16(2):181-190. DOI: https://doi.org/10.3109/10253890.2012.708950</mixed-citation></ref><ref id="B8"><mixed-citation>Salvagioni DAJ, Melanda FN, Mesas AE, et al. Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PLoS ONE. 2017;12(10):e0185781. DOI: https://doi.org/10.1371/journal.pone.0185781</mixed-citation></ref><ref id="B9"><mixed-citation>Arnsten AFT, Shanafelt T. Physician Distress and Burnout: The Neurobiological Perspective. Mayo Clinic Proceedings. 2021;96(3):763-769. DOI: https://doi.org/10.1016/j.mayocp.2020.12.027</mixed-citation></ref><ref id="B10"><mixed-citation>Khammissa RAG, Nemutandani S, Feller G, et al. Burnout phenomenon: neurophysiological factors, clinical features, and aspects of management. Journal of International Medical Research. 2022;50(9):3000605221106428. DOI: https://doi.org/10.1177/03000605221106428</mixed-citation></ref><ref id="B11"><mixed-citation>Bianchi R, Laurent E. Emotional information processing in depression and burnout: an eye-tracking study. European Archives of Psychiatry and Clinical Neuroscience. 2015;265(1):27-34. DOI: https://doi.org/10.1007/s00406-014-0549-x</mixed-citation></ref><ref id="B12"><mixed-citation>Bianchi R, Schonfeld IS, Laurent E. Is burnout separable from depression in cluster analysis? A longitudinal study. Social Psychiatry and Psychiatric Epidemiology. 2015;50(6):1005-1011. DOI: https://doi.org/10.1007/s00127-014-0996-8</mixed-citation></ref><ref id="B13"><mixed-citation>Bianchi R, Schonfeld IS, Laurent E. Burnout Syndrome and Depression. In: Kim YK, editor. Understanding Depression. Singapore: Springer Nature; 2018. DOI: https://doi.org/10.1007/978-981-10-6577-4_14</mixed-citation></ref><ref id="B14"><mixed-citation>Golonka K, Mojsa-Kaja J, Blukacz M, et al. Occupational burnout and its overlapping effect with depression and anxiety. International Journal of Occupational Medicine and Environmental Health. 2019;32(2):229-244. DOI: https://doi.org/10.13075/ijomeh.1896.01323</mixed-citation></ref><ref id="B15"><mixed-citation>Schonfeld IS, Verkuilen J, Bianchi R. An exploratory structural equation modeling bi-factor analytic approach to uncovering what burnout, depression, and anxiety scales measure. Psychological Assessment. 2019;31(8):1073-1079. DOI: https://doi.org/10.1037/pas0000721</mixed-citation></ref><ref id="B16"><mixed-citation>Verkuilen J, Bianchi R, Schonfeld IS, et al. Burnout-Depression Overlap: Exploratory Structural Equation Modeling Bifactor Analysis and Network Analysis. Assessment. 2021;28(6):1583-1600. DOI: https://doi.org/10.1177/1073191120911095</mixed-citation></ref><ref id="B17"><mixed-citation>Zisook S, Doran N, Mortali M, et al. Relationship between burnout and Major Depressive Disorder in health professionals: A HEAR report. Journal of Affective Disorders. 2022;312:259-267. DOI: https://doi.org/10.1016/j.jad.2022.06.047</mixed-citation></ref><ref id="B18"><mixed-citation>Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians: A Systematic Review. Journal of the American Medical Association 2018;320(11):1131-1150. DOI: https://doi.org/10.1001/jama.2018.12777</mixed-citation></ref><ref id="B19"><mixed-citation>Schonfeld IS, Bianchi R. From Burnout to Occupational Depression: Recent Developments in Research on Job-Related Distress and Occupational Health. Frontiers in Public Health. 2021;9:796401. DOI: https://doi.org/10.3389/fpubh.2021.796401</mixed-citation></ref><ref id="B20"><mixed-citation>Grossi G, Perski A, Osika W, et al. Stress-related exhaustion disorder--clinical manifestation of burnout? A review of assessment methods, sleep impairments, cognitive disturbances, and neuro-biological and physiological changes in clinical burnout. Scandinavian Journal of Psychology. 2015;56(6):626-636. DOI: https://doi.org/10.1111/sjop.12251</mixed-citation></ref><ref id="B21"><mixed-citation>Danhof-Pont MB, van Veen T, Zitman FG. Biomarkers in burnout: a systematic review. Journal of Psychosomatic Research. 2011;70(6):505-524. DOI: https://doi.org/10.1016/j.jpsychores.2010.10.012</mixed-citation></ref><ref id="B22"><mixed-citation>Sj&amp;ouml;rs Dahlman A, Jonsdottir IH, Hansson C. The hypothalamo-pituitary-adrenal axis and the autonomic nervous system in burnout. Handbook of Clinical Neurology. 2021;182:83-94. DOI: https://doi.org/10.1016/B978-0-12-819973-2.00006-X</mixed-citation></ref><ref id="B23"><mixed-citation>Rothe N, Steffen J, Penz M, et al. Examination of peripheral basal and reactive cortisol levels in major depressive disorder and the burnout syndrome: A systematic review. Neuroscience and Biobehavioral Reviews. 2020;114:232-270. DOI: https://doi.org/10.1016/j.neubiorev.2020.02.024</mixed-citation></ref><ref id="B24"><mixed-citation>Kakiashvili T, Leszek J, Rutkowski K. The medical perspective on burnout. International Journal of Occupational Medicine and Environmental Health. 2013;26(3):401-12. DOI: https://doi.org/10.2478/s13382-013-0093-3</mixed-citation></ref><ref id="B25"><mixed-citation>Korczak D, Wastian M, Schneider M. Therapy of the burnout syndrome. GMS Health Technology Assessment. 2012;8:Doc05. DOI: https://doi.org/10.3205/hta000103</mixed-citation></ref><ref id="B26"><mixed-citation>Kasper S, Dienel A. Multicenter, open-label, exploratory clinical trial with Rhodiola rosea extract in patients suffering from burnout symptoms. Neuropsychiatric Disease and Treatment. 2017;13:889-898. DOI: https://doi.org/10.2147/NDT.S120113</mixed-citation></ref><ref id="B27"><mixed-citation>Ivanova Stojcheva E, Quintela JC. The Effectiveness of Rhodiola rosea L. Preparations in Alleviating Various Aspects of Life-Stress Symptoms and Stress-Induced Conditions-Encouraging Clinical Evidence. Molecules. 2022;27(12):3902. DOI: https://doi.org/10.3390/molecules27123902</mixed-citation></ref><ref id="B28"><mixed-citation>Sharma S, Chawla S, Kumar P, et al. The chronic unpredictable mild stress (CUMS) Paradigm: Bridging the gap in depression research from bench to bedside. Brain Research. 2024;1843:149123. DOI: https://doi.org/10.1016/j.brainres.2024.149123</mixed-citation></ref><ref id="B29"><mixed-citation>Katz RJ. Animal models and human depressive disorders. Neuroscience and Biobehavioral Reviews. 1981;5(2):231-246. DOI: https://doi.org/10.1016/0149-7634(81)90004-x</mixed-citation></ref><ref id="B30"><mixed-citation>Willner P. The chronic mild stress (CMS) model of depression: History, evaluation and usage. Neurobiology of Stress. 2016;6:78-93. DOI: https://doi.org/10.1016/j.ynstr.2016.08.002</mixed-citation></ref><ref id="B31"><mixed-citation>Strekalova T, Liu Y, Kiselev D, et al. Chronic mild stress paradigm as a rat model of depression: facts, artifacts, and future perspectives. Psychopharmacology. 2022;239(3):663-693. DOI: https://doi.org/10.1007/s00213-021-05982-w</mixed-citation></ref><ref id="B32"><mixed-citation>Cox BM, Alsawah F, McNeill PC, et al. Neurochemical, hormonal, and behavioral effects of chronic unpredictable stress in the rat. Behavioural Brain Research. 2011;220(1):106-111. DOI: https://doi.org/10.1016/j.bbr.2011.01.038</mixed-citation></ref><ref id="B33"><mixed-citation>Pereira VH, Marques F, Lages V, et al. Glucose intolerance after chronic stress is related with downregulated PPAR-&amp;gamma; in adipose tissue. Cardiovascular Diabetology. 2016;15(1):114. DOI: https://doi.org/10.1186/s12933-016-0433-2</mixed-citation></ref><ref id="B34"><mixed-citation>L&amp;oacute;pez ALL, Villanueva MCE, Padilla MB, et al. Chronic unpredictable mild stress progressively disturbs glucose metabolism and appetite hormones in rats. Acta Endocrinologica. 2018;14(1):16-23. DOI: https://doi.org/10.4183/aeb.2018.16</mixed-citation></ref><ref id="B35"><mixed-citation>Ma J, Wang J, Wang G, et al. The potential beneficial effects of Lactobacillus plantarum GM11 on rats with chronic unpredictable mild stress- induced depression. Nutritional Neuroscience. 2024;27(5):413-424. DOI: https://doi.org/10.1080/1028415X.2023.2205742</mixed-citation></ref><ref id="B36"><mixed-citation>Dubey VK, Ansari F, Vohora D, et al. Possible involvement of corticosterone and serotonin in antidepressant and antianxiety effects of chromium picolinate in chronic unpredictable mild stress induced depression and anxiety in rats. Journal of Trace Elements in Medicine and Biology. 2015;29:222-226. DOI: https://doi.org/10.1016/j.jtemb.2014.06.014</mixed-citation></ref><ref id="B37"><mixed-citation>Машковский МД. Лекарственные средства: пособие для врачей. М.: Новая Волна; 2002.</mixed-citation></ref><ref id="B38"><mixed-citation>Lueptow LM. Novel Object Recognition Test for the Investigation of Learning and Memory in Mice. Journal of visualized experiments: Journal of Visualized Experiments. 2017;126:55718. DOI: https://doi.org/10.3791/55718</mixed-citation></ref><ref id="B39"><mixed-citation>Abel EL, Bilitzke PJ. A possible alarm substance in the forced swimming test. Physiology and Behavior. 1990;48(2):233-239. DOI: https://doi.org/10.1016/0031-9384(90)90306-o</mixed-citation></ref><ref id="B40"><mixed-citation>Porsolt RD, Anton G, Blavet N, et al. Behavioural despair in rats: a new model sensitive to antidepressant treatments. European Journal of Pharmacology. 1978;47(4):379-391. DOI: https://doi.org/10.1016/0014-2999(78)90118-8</mixed-citation></ref><ref id="B41"><mixed-citation>West AP. Neurobehavioral studies of forced swimming: the role of learning and memory in the forced swim test. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 1990;14(6):863-877. DOI: https://doi.org/10.1016/0278-5846(90)90073-p</mixed-citation></ref><ref id="B42"><mixed-citation>Ennaceur A. Tests of unconditioned anxiety - pitfalls and disappointments. Physiology and Behavior. 2014;135:55-71. DOI: https://doi.org/10.1016/j.physbeh.2014.05.032</mixed-citation></ref><ref id="B43"><mixed-citation>de Kloet ER, Molendijk ML. Coping with the Forced Swim Stressor: Towards Understanding an Adaptive Mechanism. Neural Plasticity. 2016;2016:6503162. DOI: https://doi.org/10.1155/2016/6503162</mixed-citation></ref><ref id="B44"><mixed-citation>Molendijk ML, de Kloet ER. Coping with the forced swim stressor: Current state-of-the-art. Behavioural Brain Research. 2019;364:1-10. DOI: https://doi.org/10.1016/j.bbr.2019.02.005</mixed-citation></ref><ref id="B45"><mixed-citation>Molendijk ML, de Kloet ER. Forced swim stressor: Trends in usage and mechanistic consideration. European Journal of Neuroscience. 2022;55(9-10):2813-2831. DOI: https://doi.org/10.1111/ejn.15139</mixed-citation></ref><ref id="B46"><mixed-citation>Armario A. The forced swim test: Historical, conceptual and methodological considerations and its relationship with individual behavioral traits. Neuroscience and Biobehavioral Reviews. 2021;128:74-86. DOI: https://doi.org/10.1016/j.neubiorev.2021.06.014</mixed-citation></ref><ref id="B47"><mixed-citation>Markov DD, Novosadova EV. Chronic Unpredictable Mild Stress Model of Depression: Possible Sources of Poor Reproducibility and Latent Variables. Biology. 2022;11(11):1621. DOI: https://doi.org/10.3390/biology11111621</mixed-citation></ref><ref id="B48"><mixed-citation>Sequeira-Cordero A, Salas-Bastos A, Fornaguera J, et al. Behavioural characterisation of chronic unpredictable stress based on ethologically relevant paradigms in rats. Scientific Reports. 2019;9(1):17403. DOI: https://doi.org/10.1038/s41598-019-53624-1</mixed-citation></ref><ref id="B49"><mixed-citation>Maramis MM, Mahajudin MS, Khotib J. Impaired Cognitive Flexibility and Working Memory Precedes Depression: A Rat Model to Study Depression. Neuropsychobiology. 2021;80(3):225-233. DOI: https://doi.org/10.1159/000508682</mixed-citation></ref></ref-list></back></article>