Acute Circulatory Disorders Research Articles

ОСОБЕННОСТИ ТЕЧЕНИЯ ИШЕМИЧЕСКОГО ИНСУЛЬТА ПРИ ВАСКУЛОПАТИИ И КОМПЕНСАТОРНЫЕ ВОЗМОЖНОСТИ МОЗГА. Клинический случай

Abstract. Introduction. Vasculopathies are inflammations of the walls of blood vessels, in which immunopathological processes cause endothelial dysfunction of the vessels. Changes in endothelial dysfunction are a universal pathogenetic mechanism for the development of ischemic circulatory disorders. Given the permanent development of ideas about immunopathological disorders, situations may arise with the need for revising the features of the cause of acute circulatory disorders in a particular case. Aim. To demonstrate the features of ischemic stroke in presence of vasculopathy and the compensatory capabilities of the brain. Materials and methods. A clinical case of female patient F., 77 years old, with vasculitis-associated ischemic stroke is presented. Results and Discussion. In vasculitis, the vascular walls are attacked by the body’s immune system, which leads to structural disorders. Short-term exposure of the vascular wall endothelium to the pathological factor leads to hypercoagulation, hypertonus, and production of inflammatory cytokines. It has been proven that endothelial activation is a favorable reaction that promotes an immune response to the pathogen. Cessation of the pathogenic stimulus leads to a rapid return of the endothelium from the activated state to the physiological one Accordingly, the course of ischemic stroke in immunopathological disorders may be atypical and, therefore, additional diagnostic methods and therapy correction are needed, taking into account the pathogenetic factor, considering the mechanisms of brain plasticity. Conclusions. The increasing frequency of autoimmune diseases necessitates a deeper understanding of the mechanisms, diagnostics and treatment of acute cerebrovascular accidents. Ischemic stroke with some existing brain processes develops with latent symptoms, which indicates the great compensation abilities of the brain, which can be a theoretical basis for neurorehabilitation.

Hybrid treatment of recurrent venous mesenteric thrombosis with small intestinal necrosis

The article presents a clinical case of a 39-year-old patient with thrombosis and postoperative rethrombosis of the superior mesenteric vein. The disease was complicated by the small intestine necrosis and abdominal surgical infection. Successful thrombectomy and bowel resection made it possible to restore mesenteric blood supply, to stabilize the patient’s condition and to perform an enteroenteroanastomosis. Due to antithrombin III deficiency, rethrombosis in the early postoperative period was complicated by anastomotic leak, unformed intestinal fistula and peritonitis. A hybrid treatment (surgical, parasurgical and conservative) was performed, which included selective infusion of a thrombolysis activator at the superior mesenteric artery mouth. The patient recovered.Clinical and laboratory manifestations of superior mesenteric vein thrombosis, in contrast to acute circulatory disorders in the arteriomesenteric system, are nonspecific and do not always allow timely diagnosis of intestinal ischemia. MSCT angiography identifies venous mesenteric thrombosis in most cases. The ineffectiveness of anticoagulant therapy against the background of antithrombin III deficiency caused superior mesenteric vein thrombosis and rethrombosis. The treatment of the small intestine critical postoperative ischemia included an increase in the volume of antithrombin III and frozen plasma intravenous infusion and selective administration of a thrombolysis activator (actilyse) into the superior mesenteric artery, which made it possible to restore the arteriolovenular intramural blood flow of the small intestine and to prevent another stem rethrombosis of the superior mesenteric vein. Laparostomy using a silicone plate made it possible to constantly monitor the course of the abdominal infectious process and to make timely decisions about the next intervention if medically required. The vacuum assisted design provided permanent lavage of the abdominal cavity without trauma to the soft tissues of the abdominal wall and presenting intestinal loops.

In Vivo Modeling of Complicated Necrotizing Enterocolitis

Introduction: There is no adequate and easily reproducible model of complicated necrotizing enterocolitis (NEC) that allows to study its etiopathogenesis and test various surgical treatment options in an experiment.Objective: To devise a method for in vivo modeling of complicated NEC using laparoscopy.Materials and methods: Our study was conducted at the premises of the Laboratory of Experimental Surgery and Oncology (Scientific Research Institute of Experimental Medicine, Kursk State Medical University) in compliance with international ethical standards and guidelines for humane animal treatment. Fifteen immature male rabbits underwent laparoscopy under inhalation anesthesia and then subserosal injection of damaging solutions (33% H2O2, 10% CaCl2, 4% KCl, 70% C2H5OH, 10% CH2O) into the intestinal wall. In 24 hours, we performed laparotomy, assessed pathological changes visually, and resected the section of the intestinal tube at the injection site. Then we performed a single­layer end­to­end intestinal anastomosis. Histological samples were made from a biopsy specimen. Morphological assessment of the changes was performed.Results: The most pronounced macro­ and microscopic changes were found in the animals injected with hydrogen peroxide. We assessed changes in the abdominal cavity 24 hours since the start of modeling and observed a pattern of partial intestinal obstruction and serous peritonitis. The morphological pattern was characterized by acute circulatory disorder in the intestinal wall with ulcerative necrotic defects and perforations.Conclusions: Based on morphological manifestations we devised a method for modeling complicated NEC using laparoscopy. It is easily reproducible in an in vivo experiment, close to the clinical situation, and allows to simulate typical morphological changes during severe NEC.

Age features of the thymocite RNA response in the thymus structural and functional areas to blood circulation disorders in the pool of carotic arteries in rats

Introduction. Ischemic-reperfusion injuries of the brain are accompanied by immunological disorders, which in their turn can extend post-ischemic changes in the brain. The studies of structural and functional changes in the thymus cells caused byischemia-reperfusion of the brain can supplement the existing understanding of the mechanism of the above interaction.
 The aim of the study. To investigate the reaction of thymocyte RNA in the structural and functional areas of the thymus gland to blood circulation disturbances in the carotid artery pool.
 Results. In rats of both age groups, cerebral ischemia-reperfusion reduces the content of RNA in the thymus cells in all the structural and functional areas of the thymus except the deep cortical one in one-month rats and the sub-capsular one in three-month rats. 
 Conclusions. Acute circulatory disorders in the pool of the carotid arteries result in certain changes in RNA content in all the structural and functional areas of the thymus with age-related and structural features available.

Биомаркеры ишемии органа зрения как предикторы ишемического инсульта головного мозга

Purpose. To study biomarkers of ischemia of the organ of vision in patients with acute disorders of the arterial circulation of the retina and optic nerve. Material and methods. We observed 38 patients (38 eyes). The patients were divided into two groups, the first group consisted of 26 patients (26 eyes) with acute circulatory disorders of the optic nerve (anterior ischemic neuropathy), the second group consisted of 12 patients (12 eyes) with acute circulatory disorders of the retina (occlusion of the central artery retina and its branches). The control group consisted of 12 practically healthy individuals. Results. In a biochemical study in patients with anterior ischemic neuropathy (1st group), the level of NSE in the lacrimal fluid was increased compared to the control group and averaged 32.3 ± 0.85 ng/ml, although in the blood serum it remained within the normal range , which reflects the beginning of destructive processes in the nervous tissue. In patients with acute circulatory disorders of the retina (2nd group), the content of NSE in the lacrimal fluid was increased by 1.7 times compared with the control group. Conclusion. The NSE study can be used in a comprehensive examination of patients with acute circulatory disorders of the optic disc and retina as an additional marker of the neurodegenerative process. Since data from traditional methods of research do not always show the degree of damage to the visual pathways, the study of the level of NSE helps to make assumptions about the severity of the disease and predict the outcome. Keywords: visual organ ischemia, occlusion, anterior ischemic neuropathy, central retinal artery, diagnostics, NSE protein

Epidemiology of Stroke and Survival Rate of Patients after Admission to Hospitals in Kazakhstan

BACKGROUND: According to the official statistics of the Ministry of Health, 40 thousand cases of stroke are registered annually in Kazakhstan. Meanwhile, the study of issues of organization of medical care in the admission of patients with stroke to hospitals in Kazakhstan remains relevant and requires a number of decisions to improve care. AIM: The aim of the study was to study the prevalence of stroke among the population of Kazakhstan and the organization of medical care in hospitals for the years 2018–2020. METHODS: The data were obtained from the Information System “Electronic Register of Dispensary Patients.” More than 60.0% of patients diagnosed with cerebral infarction caused by cerebral artery thrombosis were admitted to the hospital. RESULTS: The availability of medical care for stroke is of great importance. As the analysis of survival rate showed, the average survival time directly depends on the patient’s condition at admission to hospitals. The survival rate of patients with various nosologies of cerebral circulation in men and women differs significantly and reaches 80 years. CONCLUSION: The correct organization of the management of medical care for patients with acute circulatory disorders is of paramount importance. It is necessary to strengthen the integration and coordination of the systems of emergency care and primary health care.

Nodular leiomyoma of the uterus of giant size on the background of combined extragenital pathology (Case study)

The article presents a clinical case of nodular uterine leiomyoma of giant size on the background of type 2 diabetes mellitus, chronic hypertension and obesity with a classic picture of metabolic syndrome and the development of severe vascular pathology with steno-occlusive atherosclerotic lesions of the abdominal aorta bifurcation (Lerich’s syndrome) and acute circulatory disorders in the left lower extremity with gangrene of the toes of the left foot. The patient was hospitalized and comprehensively examined in the Department of Vascular Surgery of the Kyiv Regional Clinical Hospital (KRCH), which is the clinical base of the Department of Obstetrics and Gynecology №1 of the Shupyk National Healthcare University of Ukraine. The diagnosis was confirmed in the department and simultaneous two-stage surgery was successfully performed by gynecologists and vascular surgeons: first stage – pangysterectomy with revision of the abdominal organs and access to the abdominal aorta, second stage – thrombendarterectomy of the bifurcation of the abdominal aorta. In the postoperative period we restored peripheral blood flow, performed complete regression of ischemia, necrosis of the toes of the left foot dry, limited with a tendency to delimitation. Amputation of the first and second toes of the left foot was performed. Postoperative period was uneventful, on day 9 the patient was discharged home in satisfactory condition for further outpatient treatment. Diabetes mellitus type 2, chronic hypertension and obesity with a classic clinical picture of metabolic syndrome have led to the development of uterine leiomyoma and atherosclerotic changes in the abdominal aorta and main vessels of the lower extremities (Lerich’s syndrome). The successful outcome of this clinical case was made possible by the coordinated work of a multidisciplinary team of KRCH specialists both at the stage of comprehensive examination and diagnosis, and during simultaneous surgery.

Gut Barrier in Critical States of the Body

The intestinal barrier (IB) is a system of diffusion barriers separating the intestinal chyme and blood. The aim of the review is to identify the role of IB dysfunction in the formation of critical states of the body and to substantiate ways to prevent these states. Toxic substances produced by normal intestinal microflora are characterized. The involvement of endotoxin and ammonia in the pathogenesis of sepsis, acute circulatory disorders, secondary acute pulmonary lesions, and acute cerebral insufficiency is shown. Approaches to protect the IB in critical states of the body are proposed.

The experimental invasion of rats with Eustrongylides excisus (Nematoda, Dioctophymatidae) larvae during the acute course of infection

Ten laboratory rats were experimentally invaded per os with the Eustrongylides excisus (Jäegerskiold, 1909) nematode larvae (L3–L4) received from Perca fluviatialis (Linnaeus, 1758), caught in the water area of the Dnipro-Buh Estuary, Ukraine. The aim of the experimental study was to measure the pathogenic effect of the given parasite on the mammals’ organisms by means of the histological analysis of the affected organs of the infected rats. The researched animals were divided into two groups. The experiment lasted 15 days; the second group was a control group. The histological analysis showed purulent-serous and purulent-fibrinous peritonitis, acute circulatory disorders in brain tissues (signs of hypoxic-ischemic lesions of the brainstem in the form of neuronal changes) and the heart (partial spasm of arteries and edema of interstitial myocardial tissue); pathological changes in the lungs (acute interstitial purulent pneumonia, acute focal emphysema of the lungs), liver (acute exudative hepatitis), kidneys (signs of shock reaction) and intestines (acute serous-purulent enteritis). Formation of non-specific granulomas was noticed, which contained the fragments of the parasitic larvae. The acute course of the purulent-serous and purulent-fibrinous inflammatory processes in the organs of the invaded rats was noticed; signs of systemic inflammatory response syndrome with pronounced distributive vascular leukocytosis in the studied organs.

TREATMENT OF PLACENTAL INSUFFICIENCY IN PREGNANT WOMEN WITH ANTIPHOSPHOLIPID SYNDROME AND VARICOSE VEINS

In recent years, there has been an increase in the frequency of placental insufficiency (PI) in pregnant women with obstetric and somatic pathology, including in patients with varicose veins, especially in the presence of autoimmune antibodies of various etiologies. The antiphospholipid syndrome (APS) attracts more and more attention of scientists, which significantly increases both maternal and perinatal mortality [8, 9]. Most of the adverse outcomes in APS are associated with PI. One of the reasons for the development of PI are disorders of the hemostasis system in pregnant women with the presence of circulating antiphospholipid antibodies (APA). AFAs circulating in the blood plasma contribute to the activation of the platelet link of hemostasis, disruption of the hemostatic potential, and potentiation of endothelial damage. Such changes lead to local ischemia of the villous chorion, impaired placental blood flow. The consequences of pathological changes in PI in the fetoplacental system lead to hypoxia, fetal malnutrition, increase perinatal mortality, and also have adverse consequences for the development of the child [2,8,9]. Risk factors for the development of fetal malnutrition are numerous. These include various somatic diseases, disorders in the reproductive system, pregnancy complications, social factors and much more. According to the literature, in women with an autoimmune cause of miscarriage without treatment, up to 90% of pregnancies are interrupted, and the effectiveness of treatment with the most modern approaches reaches 80% or more [5, 10]. Pregnancy is a favorable condition for the implementation of the pathogenic action of AFA. The manifestation of pathological processes can occur at different times, starting from the moment of conception: the process of implantation and early embryogenesis are disrupted. According to the literature, AFAs are capable of disrupting several aspects in the process of trophoblast differentiation, which is expressed in a change in the adhesiveness of the embryo, impaired fusion of syncytium, and a decrease in the depth of trophoblast invasion; a decrease in the production of hCG, an increase in thrombotic tendencies. As a result, these changes lead to a decrease in the protein-synthesizing and hormonal functions of the placenta. In the absence of adequate therapy, thrombosis occurs in the microcirculatory bed, which causes PI, chronic hypoxia, and often fetal death due to acute circulatory disorders in the vessels of the placenta [5, 6, 10]. Among patients with PN, 16-25% of women have manifestations of varicose veins, chronic venous insufficiency and varicose veins of the pelvis. Some authors attach significant importance in the occurrence of varicose veins in pregnant women to immunological mechanisms that lead not only to functional, but also to structural changes in the vessels. As a result, a cascade of pathological changes occurs, initiated by venous stasis and hemocoagulation abnormalities, which lead to PI. Treatment of this category of patients presents significant difficulties, as it can lead to the most severe complications in obstetrics, thrombosis and pulmonary embolism [1, 3].

Role of mutations in MTHFR gene and hyperhomocysteinemia in occurrence of ischemic stroke

The objective of the study is review and analyze scientific publications devoted to the problems of stroke, its relationship with the most common mutations in the MTHFR gene and their individual allelic variants and serum homocysteine levels.Materials and methods. Analyzing foreign and domestic publications, the relationship of the strongest mutations in the MTHFR gene with an increase in the level of serum homocysteine, which is a predictor of the development of vascular accidents, including acute circulatory disorders of the brain, was revealed.Results. Stroke is a socially significant disease. All risk factors for acute cerebral stroke are subdivided into modifiable and non-modifiable. To a non-modifiable factor that predisposes to the development of ischemic and hemorrhagic stroke, hereditary factors, including genetic mutations in a number of genes. MTHFR is a genome carrying individual allelic variants that can affect the level of homocysteine in blood serum, causing it to increase, and hyperhomocysteinemia, according to a number of studies, is a likely predictor of diseases of the cardiovascular system, including severe cerebrovascular accidents. At the same time, a large number of studies use the services of the protective role of reducing the elevated level of serum homocysteine using various forms of folic acid and B vitamins. The authors of the article attempted to process, analyze and summarize the data of modern research issues on the topic under consideration.Conclusions. The relationship between the occurrence of ischemic and hemorrhagic stroke and the most common mutations in the MTHFR gene has been revealed. Hyperhomocysteinemia, separate and developing as a result of these mutations, is an independent risk factor for the development of acute cerebral ischemia. Normalization of elevated serum homocysteine levels is required for all patients as stroke prevention, and includes not only the use of foods enriched with folic acid, but also pharmacological correction of folates and B vitamins.

Modern approaches to the development of rehabilitation programs for increasing muscle strength and volume of motion in the limbs in patients after ischemic stroke

The paper presents an analysis of the data obtained on the effectiveness of the inclusion of a pulsed low-frequency electrostatic field in the standard complex of medical rehabilitation in the long-term period in 60 patients who had an ischemic stroke with movement disorders in the form of hemiparesis with an increase in muscle tone by the type of spasticity, which were divided into 2 comparable clinically — functional characteristics of the group: the main group — 30 patients who underwent a course of massage with a pulsed low-frequency electrostatic field from the «Khivamat» apparatus in addition to the standard rehabilitation complex, consisting of exercise therapy, medical massage, kinesitherapy and medication support, and the control group — 30 patients, who received only the standard complex of medical rehabilitation and drug therapy. For a comparative assessment of muscle strength and range of motion in the extremities in patients after ischemic stroke in the initial state and after the course of treatment, we used the modified Ashfort spasticity scale (MAS), Bartel’s index, and goniometry indices. Research results. Before treatment, all patients with post-stroke spasticity included in the study had impaired motor functions of the upper limb in the form of moderate hemiparesis with high muscle tone and changes in the amplitude of movement. In the initial state, all patients included in the study showed motor changes in functions in the form of moderate hemiparesis with muscle hypertonicity, a decrease in the amplitude of movement of the upper limb and a decrease in the activity of daily life. After the course of treatment, the patients of the main group showed a pronounced positive dynamics of indicators, which was confi rmed by a significant decrease by 23.8 % (p < 0,05) in spasticity in the affected limb according to the MAS scale, which decreased after 6 months by 42,8 % (p < 0.01), and after 12 months by 38.0 % (p < 0,01). In patients of the control group, significantly less pronounced and unstable results were obtained and the studied indicator decreased after the course of treatment by 14,3 % (p > 0,05), after 6 months by 19,0 % (p < 0,05), and after 12 months approached the original value. The decrease in spasticity was confirmed by goniometric data, which indicated an increase in active functional use of the hand in the main group. Conclusion: The inclusion in a comprehensive rehabilitation program of patients after acute circulatory disorders with motor disorders in the form of hemiparesis with increased muscle tone by the type of spasticity of pulsed low-frequency electrostatic massage contributes to a significant decrease in the severity of spasticity, an increase in the range of motion in the affected limbs and an expansion of daily functional independence.

Reflections on the Application of Critical Care Ultrasound in Viral Pneumonia Patients with Circulatory Dysfunction-New Classification and Precision Treatment Based on Ciritical Care Ultrasound

Viruses are among the main pathogens of pulmonary infection and tend to cause pandemics of viral pneumonia. Severe viral pneumonia tends to be accompanied by acute respiratory distress syndrome (ARDS) manifestations, displaying highly specific clinical symptoms that are most prominently expressed in the circulatory system. Shock occurred rarely, it occured at a rather late stage in this outbreak of viral pneumonia. However, because of the extensive use of critical care ultrasound, we have a deeper understanding of the characteristics of acute circulatory disorder caused by severe viral pneumonia, prompting us to reflect more thoroughly about circulatory disorders caused by other types of infections. In general, acute circulatory disorder is not uncommon in severe viral pneumonia in this outbreak, and is characterized by vascular damage, volume disorder and cardiac abnormalities of three types, high stress state, acute right ventricular dysfunction and diffuse cardiac inhibition. In the case of poor management in the early stage, these acute circulatory disorders may develop into shock, or directly cause or aggravate other organ dysfunction, for example, acute kidney injury, exacerbating the adverse outcomes. This has allowed us to reflect more thoroughly on the occurrence and development of acute circulatory disorders caused by other infections. Therefore, the classification of acute circulatory disorders based on the modular assessment of critical care ultrasound will help promote better understanding of acute circulatory disorders and further research.

P4-medicine in the resort spa treatment of patients after acute circulatory disorders

The formation of the basis for personalized medicine of the future should be based on the prognostic and preventive principles of medicine. The article presents an overview of the information on the method and application of the CME (complex medical expert) analysis. The features of the method, the object domain of its application, its task and methodology are described. The scheme of the options used to increase the efficiency of the method is of interest. The strengths and the shortcomings of the CME analysis noted by experts in the field of its application are given. Results. The authors propose an innovative technology for using the CME model to develop personalized forecasting, preservation, development, and management of health. The advantages of the technology and the urgency of its application are revealed. The new technology is based on the provisions of the development of the theory of the essential adaptation. To ensure the health state, the level of functioning of body systems must be consistent with the optimality, namely with the response norms, which determine the individual phenotype. In the process of the organism adaptation to the conditions of the external environment, the central nervous system and the significant body system (the system with the maximum response norm), which determine the specific and nonspecific responses of the organism, respectively, will be especially active (it is a known fact). Discussion. Dominant systems can actively involve other body systems in the adaptation process by the principle of interaction with them, increasing or decreasing their activity. Taking into account the direction of interaction (inhibition, toning), this fact becomes important for understanding the pathogenesis of diseases, their targeted prevention, and treatment. A comprehensive record of the mechanisms of the formation of a specific and nonspecific reaction is used with the aim of identifying and effectively preventing functional disorders in the body. The CME technology of personalized forecasting, preservation, development and health management eliminates the main drawbacks of CME analysis. On the other hand, the CME analysis technology helps to expand the range of its application, depending on the opportunities and threats of the environment. Conclusion. The presented approach will make it possible to optimally use the human potential to maintain a high quality of life and active longevity.

Complicated testicular torsion in a child

Objective. To demonstrate the possible outcome and complications of testicular torsion, the importance of timely and correct choice of treatment tactics, as well as the functional long-term results of treatment. The article describes a clinical case of complicated testicular torsion in a 14-year-old teenager with postoperative complications such as suppuration, postoperative wound failure, and partial testicular eventration, as well as treatment tactics and postoperative course of the patient. As a result of the treatment, the patient was discharged from the hospital in satisfactory condition. Conclusion. Testicular torsion is urgent disease that requires emergency surgical treatment. Acute circulatory disorders in this pathology cause significant morphological changes in the testis, resulting to the development of destructive complications, loss of organ function, and in the long term — reproductive disfunction. Even a questionable diagnosis of testicular torsion requires urgent surgery — scrototomy, revision of the testicle.

The main concepts of spa treatment of patients who have suffered acute circulatory disorders

The article offers a concise review of sanatorium — helth resort treatment of patients with pathology of cardio-vascular system. Recommendations for health resort treatment are given according to the conditions of patient’s health, the extent of illness and transportation problems. The article discusses the results of nondrags treatment in medicinal baths with thermal waters.

A Chinese consensus statement on the clinical application of transesophageal echocardiography for critical care (2019)

Transesophageal echocardiography(TEE) is valuable in intensive care unit (ICU) because its application meets the requirements of diagnosis and treatment of critically ill patients.However, the current application has not fully adapted to the specialty of critical care. TEE could be more valuablein ICU when used with a new way that under the guidance of the theory of critical care and embedded into the treatment workflow. We have expanded and improved the application of traditional TEE and integrated the concept of critical care, established the concept of transesophageal echocardiography for critical care (TEECC). Chinese Critical Ultrasound Study Group (CCUSG) organized experts in the area to form the consensus based the previous studiesand the long term practice of critical care ultrasound and TEE, aiming at clarifying the nature and characteristics of TEECC, promoting the rational and standardized clinical application and the coming researches.The consensus of Chinese experts on clinical application of TEECC (2019) were 33 in total, of whichthe main items were as follows: (1) TEECC is a significant means, which is expanded and improved from the traditional transesophageal echocardiography according to characteristics of critically ill patients and is applied in ICU based on critically clinical scenarios and requirements by the critical care physician, to promote visualized, refined and precisely management of critically ill patients.(2) TEE possesses distinctive superiority in implementation in ICU. It has characteristics of images with good quality, operations with good stability and low-dependent of operators, monitoring with continuity, and visualization with all-dimensional and detail of heart and blood vessels.(3)As a means of refined monitoring that could resulted in precise diagnosis and treatment, TEECC expands the dimension of intensive monitoring and improves the performance of critical care. (4) Indications of TEECC application include clinical etiological searching and invasive procedures guiding when it acted as a traditional role; and also refined hemodynamic monitoring based on critical care rationale and over-all management under specific critical clinical scenarios. (5) TEE and TTE assessments are complementary; they are not alternative. Integrated assessment of TTE and TEE is required under many critical clinical scenarios.(6) TEE should be a necessary configuration in ICU. (7) All-round and significant information regarding to the mechanism of acute circulatory disorders can be provided by TEECC; it is a non-substitutable means of identifying the causes of shock under some special clinical scenarios. (8) Focal extracardiac hematoma can be accurately and rapidly detected by TEE in patients with open-thoracic cardiac surgery or severe chest trauma when highly suspected pericardial tamponade.(9) The priority of pathophysiologic mechanism of septic shock can be rapidly and accurately identified by TEE; even if its pathophysiological changes are complex, including hypovolemia and/or vasospasm and/or left and right heart dysfunction. (10) Causes of hemodynamic disorders can be rapidly and qualitatively evaluated so that the orientation of treatment can be clarified by TEECC. (11) A full range of quantitative indicators for refined hemodynamic management in critically ill patients can be provided by TEECC. (12) TEECC helps to accurately assess volume status and predict fluid responsiveness.(13) TEECC is specially suitable for accurate quantitative assessment of cardiac function.(14) Mini TEE provides long-term continuous hemodynamic monitoring. (15) Standard views are easy to be acquired by TEECC, which is a premise for accurate and repeatable measurements, and a guarantee for assessment of effect and risk of therapy. (16) Compared with invasive hemodynamic monitoring, TEECC is minimally invasive, with low infection risk and high safety.(17) In patients with acute cor pulmonale (ACP) under condition of right ventricular dysfunction and low cardiac output, TEECC is a key tool for assessment. (18) TEECC should be implemented actively when suspicious of left to right shunt in critically ill patients who occurred hypotension that hard to explain the cause. (19) TEECC should be implemented actively when suspicious of right to left shunt in critically ill patients who occurred hypoxemia that hard to explain the cause. (20) TEECC is preferred in hemodynamics monitoring under prone position of ventilated patients.(21) TEECC is an imperative means to achieve over-all management of extracorporeal membrane oxygenation (ECMO) therapy, especially for all-round hemodynamic monitoring. (22) Three basic views is recommended to be used to simplify TEE assessment during cardiac arrest so that reversible causes could be identified, and resuscitation could be guided. (23) The flow related echodynamic evaluation (TEECC-FREE) workflow is preferred in refined hemodynamics monitoring and therapy. (24) Simple workflow of TEECC could be implemented in special critical clinical scenarios. (25) Application of TEECC is highly secure; however, impairments of procedure should also be alert by operators. (26) Pitfalls in application of TEE should be paid attention to by the critical care physician. (27) Timely and rationally application of TEECC is in favor of diagnosis and treatment of critically ill patients and may improve the prognosis.

Наблюдение острой кохлеовестибулопатии вертебро-базилярного генеза на фоне гипертонического криза

Cochleovestibular disorders are one of the urgent problems in otorhinolaryngology, due to the high incidence and insufficient efficacy of treatment. According to some researchers, cochleovestibular disorders in most cases are of vascular nature (73.0%), which is one of the reasons of the increase in the number of patients. We present a clinical case of acute cochleovestibulopathy of vertebro-basilar genesis, in the form of a momentary acute circulatory disorder in the inner ear and cervical positional vertigo associated with the hypertensive crisis. A female patient B., 61 years old,, visited the ENT Department of Karachay-Cherkess Republican Clinical Hospital with the complaints of acute hearing impairment in the left ear, noise in the ear, pain in the neck and short-term attacks of systemic rotational vertigo, accompanied by nausea when turning the head to the left and throwing it back. The otoneurological examination revealed the symptoms of left-side peripheral cochleovestibular syndrome: profound deafness, reduction of vestibular excitability on the left. De Klein test revealed right fine, binocular, associated, fast, horizontal-rotary degree 2 nystagmus. This clinical case is unusual because atherosclerotic lesion of the right vertebral artery and hypoplasia of the left vertebral artery in combination with arterial hypertension initiated a momentary occurrence of acute circulatory disorders in the inner ear and cervical positional vertigo.

Wide awake hand surgery based on application examples

Anesthesiologic method with low bleeding level, risk level, and complication rate for surgical procedures on the hand without atourniquet on an unsedated patient with the possibility for functional testing during surgery. Surgical procedures of the hand can be carried out using the wide awake technique depending on the patient's suitability and preference considering individual risk factors. Absolute contraindications are allergies to the local anesthetic or its components. Relative contraindications are severe hepatic or renal insufficiency, infections in the injection area, acute circulatory disorders, or higher cardiac function impairment. Infiltration of alidocaine/epinephrine mixture with 8.4% sodium bicarbonate in aratio of 10:1.5 at least 30 min prior to surgery. Perpendicular puncture of the skin and slow injection. Continue injection until reaching apale skin area of at least 1 cm around the entire operating area. If the needle tip always remains in acushion of local anesthetic, a"hole-in-one" anesthesia can be achieved (only the first needle puncture is felt). Elevated care and awareness for numb body parts by the patient because of impaired sensation. Follow-up treatment according to the surgeon's specifications. Postoperative use of painkillers. Of 38patients, 32felt that the procedure was not stressful, 6rated it as abit stressful. Pain perception on avisual analog scale (0 = no pain, 10 = severe pain) scored an average of1.6 during infiltration, 0.5during the operation, 3.5during the reduction of the anesthesia, and 2.9on the following day. All patients would undergo surgery again using the wide awake technique.

PATHOLOGIC FEATURES OF PERIODONTAL TISSUES IN EXPERIMENTAL OSTEOPOROSIS

The article presents information about some pathological changes in periodontal tissues during experimental osteoporosis. The experiments were conducted on 8 three-year sheep, which have at different times after ovariectomy removed dentoalveolar segments in the region of incisors of the lower jaw. Pathological changes in periodontal animals in experimental osteoporosis were local manifestations of the general condition of the body that are typical of acute hypoxia mixed character. It was found that experimental osteoporosis in periodontal develop processes accompanied by acute circulatory disorders, which worsen the conditions of metabolism, which ultimately leads to destructive changes of argyrophilic and collagen fibrils, as well as individual nerve fibers. Studies have shown that these effects are reversible, and after 120 days to the fore the phenomenon of compensation in periodontal starting to recover basic histological structure. Prolonged hypoxia, as the main link in the pathogenesis of degenerative and inflammatory of forms of periodontal disease may be modified by the proven of efficiency pharmacological means. The detected changes at the osteoporosis models can be the basis for further study of the role of autologous mesenchymal stem cells and materials-matrices of various origins in optimizing the osseointegration process.