Invasive procedures (surgery, endoscopy, biopsy) used in the Russian Federation (RF) have been discussed previously [1]. Among other things, the following topics were discussed: removal of pectoral muscles at mastectomy, overuse of gastrectomy for peptic ulcers, of thoracic surgery for tuberculosis, bronchial asthma and other respiratory diseases, unnecessary operations in diabetes mellitus, overtreatment of thyroid lesions, excessive therapy of patients with alcohol use disorder, cauterization of cervical ectopy regardless of the presence of epithelial dysplasia [1]. Foreign literature is available gratis on the Internet, many guidelines being adjusted to international standards. Some Russian handbooks are partly copied from the Internet without references, commented and illustrated in the books [1,2]. Documentary evidence of manipulations with statistics, misquoting and falsifications is provided as illustrations. Some human factors have remained largely unchanged: paternalism, authoritative management style, occasional disregard for the principles of informed consent, professional autonomy and scientific polemics. One of the motives for excessive use of surgery and other invasive procedures is the training of medical personnel under the imperative of readiness for war. This review is focused on the excessive use of renal and bladder biopsy, overdiagnosis and overtreatment.

The I.M. Sechenov Medical Academy (recently renamed University) in Moscow has been the leading institution in the field of nephrology and nephropathology. Numerous textbooks, manuals and journal articles emerged from the Academy; many of them are cited here. As for morphological methods, the electron microscopy was not always used for diagnostics. Nevertheless, about one third of the biopsy cylinder was embedded in epoxy resin, usually remaining unavailable for diagnostic purposes. The semi-thin resin sections were made for research but were not used for the diagnostics (images are in [1]), the latter performed mainly on the basis of paraffin sections and immunofluorescence for immunoglobulins, complement fractions and fibrinogen. The histological stains mostly used for the diagnostics were hematoxilin and eosin (H&E), Periodic acid-Schiff (PAS), Congo red and van Gieson’s stain. On the contrary to the international practice, silver stains were not used for the routine diagnostics. Later on, the silver, Masson’s trichrome, other stains and immunohistochemical methods started to be used in some laboratories.

Glomerulonephritis

RB has been generally regarded by the Russian literature to be indicated for patients (including children) with suspected glomerulonephritis (Gln). According to the international literature, RB in isolated proteinuria and isolated microhematuria without renal insufficiency may not be warranted. Nevertheless, RBs were taken from individuals with “inactive nephritic” or latent forms of supposed Gln [3-10]. At the same time, classifications of Gln have been different from those used internationally, which impeded implementation of guidelines from the foreign literature. For example, IgA nephropathy was not regarded as a separate entity; it was not mentioned even in the article from the I.M. Sechenov Academy (the leading institution in this and many other fields) on the “hematuric form” of Gln [11]. IgA nephropathy was usually diagnosed on RB as mesangioproliferative Gln (MPG) and treated with corticosteroids and cytotoxic drugs [12-20]. In more recent editions, controversies can be found: in the textbook [21], IgA nephropathy and Berger’s disease are discussed separately and different treatments are recommended. Original classifications of glomerular diseases were invented [22]. It should be mentioned that in the latter study morphometric methods proposed earlier [23] were used without reference. In the National Manual, an authoritative Russian-language edition in nephrology, IgA nephropathy and MPG are discussed in one chapter titled “Mesangioproliferative (IgA) Gln” as follows (from Russian): “The term IgA nephropathy is used to designate an entity, the morphological equivalent of which is MPG” [24]. This does not agree with the known fact that glomeruli in IgA nephropathy may be inconspicuous at light microscopy, may exhibit morphological features of various Gln types, segmental mesangial proliferation and/or focal sclerotic lesions [25].

Comparisons of percentages of glomerular conditions, diagnosed by RB in Moscow and Rostock (Table 1) [26,27] are suggestive of habitual false positive diagnosis of Gln, and hence unnecessary therapy with corticosteroids and cytotoxic drugs. This practice continued for decades, the central figures being Vladimir Varshavsky and Maria Ratner [3-5,9,11,13-15,20,22,26]. The author of this review participated in a research using epoxy resin sections cut by a modern LKB pyramitome with glass knives [28]; after that he found it difficult to examine diagnostic paraffin sections, less clearly visualizing basement membranes and mesangial matrix; images are in [1]. Nonetheless, the epoxy resin sections were used only for research. The paraffin slides used for the diagnostics were relatively thick, the thickness being uneven. Overstained or thick sections can mimic a glomerular capillary wall thickening. This is a probable reason why membranous Gln was diagnosed in Moscow more than twice as frequently as in Rostock (Table 1). In recent studies from Germany, Japan and the United States, percentages of both Gln in total and of IgA nephropathy plus membranoproliferative Gln [29-31] were lower than in I.M. Sechenov Academy, which agrees with the above conclusion about false-positivity. Finally, the more frequent detection of focal/segmental Gln in Rostock (Table 1) indicates thinner sections required for this diagnosis.

The diagnosis of MPG was used broadly, encompassing 55.5-60.8 % of all Gln cases detected by RB at the I.M. Sechenov Academy [26,32]. The problem was publicly discussed by the author of this review, and the percentage of MPG decreased to 48.9% [33]. Epoxy resin sections and silver stain were not used for the diagnostics, while electron microscopy, applied for the research, was used for diagnostics only occasionally. Using these methods, the collecting box of MPG could have been partly sorted out, excluding from it cases with minimal morphological abnormalities, that is, isolated proteinuria and/or hematuria without renal or systemic disease, not requiring corticosteroids and cytotoxic therapy.

Table 1: Percentages of Glomerular Diseases Diagnosed by Renal Biopsy in Moscow and Rostock, Germany [26,27].

As mentioned above, RBs were collected from patients with “inactive nephritic” or latent clinical types of Gln i.e., minimal proteinuria and/or hematuria. As a result of the histological overdiagnosis, some patients were treated with corticosteroids and immunosuppressive drugs such as azathioprin, cyclophosphamide or chlorambucil [3-5,12] without indications. Of note, 83.5 % of MPG cases were classified clinically as inactive nephritic type of Gln [3]. In this connection, it is not surprising that the 18-year survival rate of patients with the inactive nephritic Gln type was reportedly as high as 100 % [3]. It also indicates the young age of the overtreated patients. In another paper by the same researchers, the “actuarial survival” up to 18 years approached 100% [32]. Elsewhere it was stated that active therapy of Gln allowed elevating the 10-year renal survival to 100% [4]. The difference in meaning between the statements quoted above is minimal in view of the low prevalence of dialysis and of functioning kidney transplants in RF [34]. Considering comparatively shorter survivals in the international literature, the figures up to 100% [3,4,32] indicate false-positivity.

Pyelonephritis

Core and wedge RB is generally not indicated in pyelonephritis. We have found in the literature no research based on RB in acute disease (apart from the studies discussed below). The research based on RB in chronic non-specific pyelonephritis outside RF was completed in the 1960s [35]. In some studies, wedge RBs were taken at kidney-preserving surgeries such as lithotomy from patients with chronic or acute (including purulent and abscess-forming) pyelonephritis [36,37]. In the international literature, pyelonephritis is not listed among indications for RB, while hydronephrosis and infections of the upper urinary tract are presented as contraindications. In particular, wedge RB in acute pyelonephritis is obviously associated with the risk of abscess formation. In another study of pyelonephritis, including its acute and chronic varieties, RBs were collected both from cortical and from medullary layers. In the Urology Clinic of the I.M. Sechenov Medical Academy, wedge RBs measuring 0.5-1 cm were taken at kidney-preserving operations (lithotomy, ignipuncture, revision of the renal vessels), including operations on a single kidney [36-38]. In the studies from the same academy, RBs were collected from patients with chronic pyelonephritis and hydronephrosis, while conclusions were based on linear correlations between ultrastructural morphometric and clinical data [39,40]. However, statistical significance of the correlation coefficients in these and some other studies was overstated. A comparison with reference tables demonstrated that many claimed P-values were too low for the given correlation coefficients and quantities of correlation pairs in the studies [39-43]; more details and references are in [1,2]. In a later study, renal medullary tissue was studied using RBs collected during lithotomy operations from patients with pyelonephritis [44], a procedure obviously associated with the risk of infectious complications. Core RBs were taken from patients with the same condition also by other researchers [45]. Fine-needle RB in acute pyelonephritis was performed and recommended as well [46].

Alcohol-Related Conditions

Among patients with supposed alcoholism, biopsies were collected from kidneys, pancreas, liver, lung, salivary glands, stomach and skin, sometimes repeatedly [47-51]. Intraoperative lung biopsies were taken from patients with purulent pulmonary conditions [51]. In many cases the tissue fragments from various organs were collected for research without clinical indications. The attitude to supposed alcoholics has sometimes been less responsible than to other patients.

Furthermore, RBs were taken from individuals with chronic alcoholism and nephritic symptoms, while “intracapillary proliferative Gln” was identified in a majority of cases [52]. In a subsequent study by the same team, the histopathological diagnosis in 40 of 43 alcoholics with nephritic symptoms was mesangiocapillary Gln; while in 29 of 31 individuals with nephritic symptoms but no alcoholism, "fibroplastic" Gln was detected [53]. The highly significant difference between the two groups created doubt concerning reliability. Other invasive techniques performed without clinical indications in individuals diagnosed with alcohol use disorder have been discussed in the books [1,54]. Repeated invasive manipulations performed in conditions of insufficient procedural quality was known to cause viral hepatitis: some patients became jaundiced after a hospitalization. It is not surprising that anti-HCV antibodies were found to be sevenfold more frequent in Russian alcohol abusers than in the general population [55]. The combination of alcohol-related and viral liver damage is known to be unfavorable.

Congenital Renal Conditions and Malformations

The original concept of hypoplastic renal dysplasia was developed on the basis of pediatric RBs, described as follows: “Racemosely arranged glomeruli with single capillary loops, abundant rounded cells freely lying in the cavity of a capsule; single mesangial cells; irregular enlargement, loosening, and thinning of the basement membrane”, narrow extracapillary space, glomeruli having irregular form and singular capillary loops or total absence of capillaries [9,56], which has no analogues in the international literature. The terms “renal hypoplasia” and “dysplasia” are used in the literature with different meanings. Apparently, the descriptions were at least in part based on tangential sections of glomeruli, which is evident from the illustrations in the articles [56,57]; the images were reproduced and commented in [1,2]. It was recommended to the authors to verify their concept counting glomeruli “with singular capillary loops” [56] in autopsy or nephrectomy specimens, but it has not been done. The common feature of suchlike papers is the presentation of ultrastructural findings without comparison with light-microscopic images, while variants of the normal structure, artefacts and accidental findings were interpreted as specific phenomena. For example, hypoplastic dysplasia was diagnosed by electron microscopy in 8 from 34 randomly selected patients with nephrotic syndrome and histologically minimal glomerular changes [58]. At the same time, there were neither cases of Alport syndrome nor of thin basement membrane nephropathy among 4440 overviewed RBs [33]. Both latter conditions comprised >1% of all RB diagnoses in Germany [27] and 1.3% in Japan [31]. The concept of hypoplastic dysplasia was discussed with clinicians collecting biopsies from children, which could have impeded the diagnostics of Alport syndrome. The latter is of importance for genetic consultation of the patients.

Later on, the same researchers applied the term hypoplastic dysplasia to the glomerular changes in congenital hydronephrosis and other renal malformations in children, interpreting them as inborn nephropathy diffusely affecting glomeruli [59-62]. A regular combination of diffuse glomerulopathy and hydronephrosis due to ureteropelvic stenosis seems to be improbable. Glomerular changes in hydronephrosis caused by urine retention (collapse of the glomerular tuft with the widening of urinary space) are different from those described within the scope of “hypoplasia” and “dysnephrogenesis” [57]. For this latter research, 167 intra-operative RBs from children with supposed urogenital malformations, and RBs for the control group from adult urological patients, had been collected [57,63].

Renal and Pancreatic Biopsies in Diabetes Mellitus

The same research team harvested wedge biopsies from pancreas during the operations “pancreatic blood shunting into the systemic blood flow in insulin-dependent diabetics”, discussed in detail previously [1]. From the same patients, core RBs were collected [64]. Gln and mesangiolysis were designated as consecutive stages of diabetic glomerulosclerosis [65]. Ultrastructural descriptions included interposition with displacement of mesangial cells to the periphery of glomerular capillary loops and formation of double-contour basement membranes [65,66], which is typical for membranoproliferative Gln. Morphological features of Gln, if found in a diabetic patient, are usually interpreted as a superimposed condition possibly needing immunosuppressive therapy. It should be commented that in diabetes mellitus, RB is generally indicated for patients with suspicion of non-diabetic renal disease, in rapidly progressive decline of kidney function and/or sudden development of nephrotic proteinuria [67,68].

Renovascular Hypertension

RB in renovascular (vasorenal) hypertension, applied in RF, has been discussed in [1,2]. RB in this condition is generally not indicated. Some risk for patients could have been caused by bilateral renal biopsies taken for research [40,69-71]. Details should be further commented: “Mathematical model of renovascular hypertension” [69,70,72], “Renal endocrine system” and its “stereotype cyclic changes” in various renal conditions [42].

The English summaries, available also on the PubMed, are quoted as examples of doctrinairism:

“Comparison of the findings of clinical, instrumental, and laboratory examination of patients with vasorenal (renovascular) hypertension with the results of morphological analysis of renal bioptic material showed that multivariate regression analysis of the parameters of examination of the patients provides for authentic calculation of the quantitative index of nephroarteriolosclerosis - the vascular index of the afferent arterioles of the renal glomeruli. The calculated values of the vascular index for both kidneys are criteria for choosing the method of operative intervention in vasorenal hypertension” [72].

Comment: At that time the author of this review worked at the same department and examined, among others, biopsy specimens from patients with renovascular hypertension; they were usually small, most of them contained no more than 1-3 glomeruli and arterioles, while some specimens contained none of these structures at all. There were also larger wedge biopsies [40]. A majority of the specimens were unsuitable for a reliable morphometric assessment, let alone “choosing the method of operative intervention in vasorenal hypertension” [72].

Another summary:

“The renin-angiotensin (juxtaglomerular apparatus - JGA) and prostaglandin (interstitial cells (IC) of renal medulla and nephrocytes of collecting tubules (NCT) systems of the kidneys were studied in 72 patients (renal biopsies, nephrectomy, morpho-functional correlations) with the nephrogenic arterial hypertension (vasorenal hypertension, chronic glomerulonephritis, pyelonephritis). Histologic and electron-microscopic methods were used; the renin activity was determined in the peripheral blood and blood from the renal veins. The results were analyzed mathematically and statistically using an original program. It is shown that stereotype cyclic changes develop in the endocrine renal system of patients with renal hypertension and that they reflect the stages of initial hyperfunction (ultrastructural hyperplasia of JGA cells with appearance of numerous immature granules; ultrastructural moderate hyperplasia of medulla IC; increase of blood renin activity), discoordination of functions (progressing JGA hyperfunction and depletion of prostaglandin synthetic function of medulla IC; compensatory activation of NCT; further increase of the blood renin activity) and depletion (atrophy and fibroblastic transformation of the JGA of the majority of nephrons and of medulla IC). The stages of renal endocrine system alterations in the arterial hypertension are the manifestation of compensatory and adaptive response. Morphofunctional analysis with the use of morphometry and mathematical statistics are necessary for the objective evaluation of this response” [42].

In the late 1980s, the author of this review searched through the archive of ultrastuctural images on photographic paper and glass plates, having found 20-30 images of juxtaglomerular cells with secretory granules having similar structure, probably originating from a small number of patients and experimental animals. These photographs were used as illustrations in the dissertation [40] and other publications. There was not enough material for a reliable statistical assessment of morphometric data characterizing “the elliptical shape of the granules in the JGA epithelioid cells”, relative volumes of secretory granules and organelles [40,43,71]. Human renomedullary interstitial cells, bona fide suitable for the assessment of prostaglandin synthesis, were absent in the archive. There were only a few ultrastructural images, repeatedly used as illustrations in different publications; some images are reproduced and commented in [1,2]. The phenomenon referred to in the above-quoted summary as a “compensatory activation of nephrocytes of collecting tubules (NCT)” [42], the proposed morphologic equivalent of enhanced synthesis of prostaglandins or other antihypertensive factors, has never been satisfactorily illustrated. The data about “stereotype cyclic changes in the endocrine renal system” [42] in Gln, pyelonephritis, and other renal conditions, as well as “calculated values of the vascular index for both kidneys” as indication for surgery in renovascular hypertension [72] have never been confirmed by other researchers.

According to the papers discussed above, renal tissues from patients with chronic pyelonephritis, Gln and renovascular hypertension (both kidneys) underwent ultrastructural morphometry [40,42,71]. It should be commented that sufficient numbers of representative sets of ultrastructural images have never existed. The author observed how this morphometry was performed: it was done using ultrastructural images on the photographic paper about 10 cm in size, by means of a ball-point pen connected to an image analyzing system (images are in [1]). Only granule-containing cells were processed; the mean level of granularity was not representatively determined even for a single JGA, let alone assessment of different JGAs from the same patient. Secretory granules were measured together with nonspecific lipofuscin-like granules, known to be a potential source of confusion when estimating the degree of granularity [73]. Moreover, the common practice was selecting suitable images independently of their origin, the single most important consideration being their fitting into the concept.

Bladder Biopsy and Cystoscopy

Obviously, the diagnostic reliability depends on the quality of histological specimens. If the sections are thick, urothelium may appear hyperchromatic. Combined with tangential sectioning, this may result in a picture resembling dysplasia. In the presence of inflammation, basement membranes may be obscured and distorted, in places mimicking microinvasion. Another difficult differential diagnosis is between a papillary urothelial neoplasia with inverted growth and inverted papilloma. Furthermore, a mimicker of a papillary urothelal neoplasm is polypoid cystitis. Some histological variants of bladder cancer can be difficult to distinguish from benign conditions such as cystitis cystica, proliferative von Brunn nests, nephrogenic adenoma and inverted papilloma. Details and illustrations are in textbooks e.g. [74].

Diagnostic uncertainty is a probable explanation for the fact that in different groups of men with benign prostatic hyperplasia (BPH) and women with chronic cystitis, from the territories contaminated after the Chernobyl accident and Kiev (not officially belonging to the contaminated territories), severe urothelial dysplasia and carcinoma in situ (CIS) were found by bladder biopsy as frequently as in 56-92 % of random cases [75-78]. The random selection was pointed out: “The Institute of Urology in Kiev during 1994-2006 collected all BPH patients who underwent suprapubic prostatectomy, and all these patients were included in our study in different years without exception” [77]. In a printed handout, distributed at the 23rd IAP Congress in Nagoya, the following was reported: “Histologically the different forms of proliferative cystitis, which were frequently combined and had features of irradiation cystitis with multiple areas of severe dysplasia and carcinoma in situ CIS, sometimes associated with small transtional-cell carcinoma, occurred in 97 % of patients from the radiocontaminated areas.” The prevalence of neoplastic and precancerous lesions quoted above is obviously unrealistic. The topic of cystectomy has been avoided by researchers quoted above. It can be reasonably assumed that some bladders have been removed based on questionable histological diagnoses of urothelial carcinoma in situ and microinvasion. The images have been reproduced in [1,79]. So-called Chernobyl cystitis or “irradiation cystitis” [77,80], characterized not only by dysplasia and CIS but also by “reactive epithelial proliferation associated with hemorrhage, fibrin deposits, fibrinoid vascular changes, and multinuclear stromal cells” [80], was at least in part caused by repeated cystoscopies, “mapping” biopsies, and electrocoagulation.

It was argued in the authors’ reply [81] that the activity concentration of the radioactive isotope cesium-137 in the urine of patients from the most severely exposed group was on average 6.47 Bq/liter, which allegedly had been the cause of neoplastic and precancerous lesions in the bladder mucosa. For comparison, the guidance level for cesium-137 in drinking water, recommended by the World Health Organization (WHO), is 10 Bq/liter [82]. This activity concentration corresponds to the dose of 0.1 mSv from annual consumption of drinking water (assumed to be 730 liters). Moreover, cesium behaves in the body similarly to potassium, the main excretory pathway being urine [83]. This implies that cesium concentration in urine would normally be higher than in the drinking water because of the renal concentration. Natural background radiation exposures vary widely: the global average is 2.4 mSv/year with the local levels being 10 times higher or even more without reliably proven health risks [84,85]. An increase by <0.1 mSv due to the consumption of water containing ~6 Bq/liter of cesium-137 is a negligible addition to the natural background level.

Furthermore, in the authors’ reply [81], the argument was proposed that the patients with BPH have dilated bladders, which causes “urinary retention and therefore presumably high radiation exposure to the urothelium.” However, most of the beta-particles (94.5%) emitted by the cesium-137 radioactive decay, having maximal energies of 0.51 MeV [86], can penetrate in water for ~2 mm [87]. In urine, which is electrolyte solution, the penetration distance of charged beta particles (electrons) would be shorter. The additional bladder filling is insignificant for the urothelium injury by beta particles. Gamma rays would cause less radiation injury in the thin urothelial layer than beta particles, because of a longer penetration distance [88]. Excessive filling of the bladder would probably reduce absorption of both gamma and beta rays within the urothelial layer because of its thinning due to stretching. In any case, the reported cesium-137 activity concentration 6.47 Bq/liter in urine is too low to cause any increase in bladder malignancy or the “radiation induced chronic proliferative atypical cystitis”, called Chernobyl cystitis, reportedly associated with multiple areas of urothelial dysplasia and CIS [76,89].

The flat CIS is frequently found concomitantly with papillary or invasive carcinoma. If left untreated, CIS may progress to invasive cancer. The high frequency of bladder CIS, reported in random patients with BPH, is incompatible with the bladder cancer incidence (50.3 cases per 100,000 inhabitants and year) mentioned by the same researchers [81]. It is known that urothelial dysplasia can overlap with cytological abnormalities seen in reactive conditions, which could have contributed to overdiagnosis of dysplasia and CIS. The use of both latter terms should be limited to those cases where it is certain that the cytological abnormalities are of neoplastic nature. To prevent overtreatment, reactive atypia and that of unknown significance should be described as such [90]. Of note, the articles [77,91] reuse the same images of insufficient quality. Looking at these and earlier illustrations by the same authors [92,93], it seems that false-positive conclusions on dysplastic and neoplastic bladder lesions had taken place also back in the 1980s, when the author smelled a rat: both articles published 3 years apart used one and the same poor quality image of bladder leukoplakia with invasion (according to the captions) [92,93], which is not clearly recognizable. The images have been reproduced and commented in [1,79].

In fact, the radiation-induced changes of squamous and transitional epithelium (vacuolization etc.), known from studies of tissues from patients after radiotherapy, are absent in the images [77,91], which was commented by the authors: “Classic descriptions of acute and chronic radiation effects on the urinary bladder do not coincide with the pathogenesis of human urinary bladder injury after long-term, low-dose exposure to ionizing radiation” [77]. The histopathological images of bladder mucosa and thyroid, potentially conducive to overdiagnosis, published in widely used Russian-language textbooks on tumor histopathology [94,95], have been reproduced and commented [1,96].

Analogous overtreatment tendencies could have taken place in regard to renal lesions studied by the same research team. Surgeons might overuse nephrectomy instead of kidney-preserving procedures if they read that renal-cell carcinoma from radiocontaminated territories is on average more aggressive, while surrounding parenchyma contains “proliferative atypical nephropathy with tubular epithelial nuclear atypia and carcinoma in situ” [97]. As discussed previously, supposed higher aggressiveness of renal cancer from radio-contaminated territories was probably caused by the averagely later cancer detection compared to Spain and Colombia, from where control cases had come from [98-100].

In conditions of paternalism, misinformation and persuasion of patients are regarded to be permissible. Suboptimal practices have been used as per instructions by healthcare authorities and leading experts’ publications. Invasive procedures applied without evidence-based indications have been reviewed elsewhere [1]. The same considerations pertain to RB. The RB material used in certain studies discussed above was unique: wedge or core biopsies from patients with hydronephrosis, acute and chronic pyelonephritis. The harvesting of specimens is associated with risks; while reliability of some results and conclusions has been questionable. Apart from the articles discussed here, no other studies based on RB in hydronephrosis and acute pyelonephritis are known to us, while in chronic pyelonephritis no large studies performed abroad since the 1960s have been found. In particular, wedge biopsy from kidney in acute pyelonephritis may result in abscess formation. Overdiagnosis of MPG resulted in the overtreatment with immunosuppressive drugs. High quality of specimens and of their examination must be a precondition for the use of RB in research and practice.

The Soviet period brought about an expansion of admission numbers to universities and medical educational institutions, sometimes with little regard for the quality of preparation of students. Some invasive methods with questionable indications were introduced or advocated by military surgeons. One of the motives for the overuse of invasive procedures has been personnel training under the imperative of readiness for war. Military and medical ethics are not easy bedfellows. The comparatively short life expectancy in Russia is a strategic advantage as it requires smaller investment in healthcare and pensions. Malignancies are diagnosed in RF relatively late. Furthermore, among factors contributing to the use of invasive procedures with questionable indications have been the partial isolation from international scientific community, insufficient consideration of the principles of professional autonomy, informed consent and scientific polemics as well as a paternalistic attitude towards patients. Lack of coordination and partial isolation from the international community resulted in parallelism in research and unnecessary experimentation. Considering shortcomings of medical practice, research and education, government directives and increase in funding are unlikely to be a solution. Measures for improvement of the healthcare in RF must include participation of authorized foreign advisors. 

Declaration

No conflict of interest.

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