City Clinical Hospital Research Articles

Differential approach to the diagnosis and treatment of appendicular peritonitis in children

The incidence of appendicular peritonitis (AP) is 3-4 % among all acute surgical diseases in children, and the structure of acute appendicitis in recent decades fluctuates within 10-15 %. Timeliness and informativeness of acute abdomen diagnostics remain important tasks of clinical practice. The use of laparoscopy with its possibility of diapeutic approach allows to diagnose and eliminate the cause of the disease. On the basis of the surgical department of the Children's City Clinical Hospital No. 1 in Nizhny Novgorod. In the period from 2018 to 2022, 126 (11.2%) patients with various types of AP were treated in Nizhny Novgorod. All children were examined with assessment of general and local status, laboratory tests were performed using unified methods developed for practical healthcare. In complicated or doubtful cases, ultrasound of the abdominal cavity organs was performed (Vivid-7 of expert class using high-frequency transducers: convex (frequency up to 5 MHz) and linear (frequency up to 10 MHz). Local forms of AP prevailed – 90 %, of which appendicular abscess was found in 35 % of observations. Data of anamnesis, examination of patients, assessment of purulent-inflammatory markers in complicated and controversial situations were resolved by ultrasound of abdominal cavity organs. Instrumental diagnostics allowed them to detect anechogenic contents (effusion), delimited areas of absceding between the intestinal loops, perforation defect of the appendix wall, periappendicular abscess forming. Within the framework of surgical correction the priority was given to laparoscopy (59.5 %), a modern therapeutic and diagnostic method with a diapeutic approach. Open interventions were used in 51 (49.5%) patients, of which: Sprengel's access was performed in 31 (61%) patients, Volkovich-Dyakonov was used in 19 (37%) cases, midline laparotomy was performed in 1 child. Analysis of the results of bacteriological studies allowed us to identify the leading pathological pathogens belonging to Gram-negative or Gram-positive flora. In the postoperative period, therapy corresponding to the treatment of patients with peritonitis was prescribed. Evaluation of bacteriological examination revealed that Enterobacteriaceae (87%), non-fermenting bacteria (72%) were susceptible to all antibiotics. However, the highest susceptibility (73 %) was noted to cephalosporins. All children were discharged home in satisfactory condition, with an average bed-day of 12.32 ± 2.4.

Immediate and long-term results of the use of balloon angioplasty with stenting in the treatment of renal graft arterial stenosis

Aim. To assess the safety and efficacy of percutaneous transluminal balloon angioplasty with stenting for renal graft artery stenosis. Material and methods. From June 2018 to December 2022, 344 kidney transplants from a deceased donor were performed at the surgical clinic of City Clinical Hospital n.a. S.P. Botkin. The study group consisted of 220 men (63.9%) and 124 women (36.1%). The mean age was 46.46±11.74 (19–73) years. With a mean follow-up period of 20.05 (1-54) months, stenosis of the renal graft artery was diagnosed in 4 patients (1.16%). The mean time from transplantation to the diagnosis of stenosis was 4 (1–9) months. In addition, we diagnosed the development of this complication in 4 kidney transplant recipients operated in other centers. The mean time from transplantation to the diagnosis of stenosis in these patients was 103.25 (12–221) months. Thus, we have the experience in the treatment of renal transplant arterial strictures in 8 recipients: 4 men (50%) and 4 women (50%). The mean age was 48.25±11.97 (27–60) years. Stenosis was manifested by renal graft dysfunction with a progressive increase in urea and creatinine in 6 patients (75%), by arterial hypertension in 2 patients (25%). The mean, level of creatinine at the time of diagnosing stenosis was 290.75 (157–494) µmol/L, glomerular filtration rate was 22.87±12.19 (8–41) ml/min/1.73m2 . Results. In the early postoperative period, 1 complication was recorded in the form of pulsating hematoma of the common femoral artery, which required surgical intervention (complication class IIIA according to Clavien-Dindo). The mean hospital postoperative bed-days made 5.22 (4-8). The mean follow-up time was 22.75±7.4 (14–33) months. All recipients were alive throughout the whole follow-up period. In 7 of 8 recipients (87.5%), the graft was functioning, in 1 patient a progressive graft dysfunction was noted, for which chronic hemodialysis was started. Mean creatinine in recipients with a functioning graft was 156.71±33.4 (123–200) µmol/L; mean glomerular filtration rate was 41.57 ml/min/1.73m2 . Conclusions. Percutaneous transluminal balloon angioplasty with stenting is a safe and effective minimally invasive technique and should be considered as the operation of choice in the development of renal graft artery stenosis.

Method for Evaluating the Effectiveness of Simulation Training
 for Laparoscopic Intracorporeal Suturing

Laparoscopic intracorporeal suturing (LIS) is one of the key skills in laparoscopic surgery. LIS training is conducted in simulation centers and is aimed at transferring the knowledge into practice. The simulation training (ST) is focused on the development of skills that allow surgeons to perform LIS operations. However, this goal is not completely achieved: only 44,0 to 72,2 % of surgeons implement LIS skills in their practice. 
 There is a need to evaluate the effectiveness of such training programs and analyze factors that may influence the results. This evaluation is required to increase the effectiveness of LIS trainings and implement the acquired skills into practice by training surgeons. 
 According to commonly accepted approach to evaluation of training programs suggested by D. Kirkpatrick., the method of effectiveness evaluation allows to estimate the practical results achieved by all trainees. Unfortunately, there are no commonly accepted methods aimed at evaluating the effectiveness of LIS training programs. The existing methods estimate the results of effectiveness evaluation in simulation (Dry lab) or practically, but in small groups. Effectiveness evaluation of LIS trainings implementation in surgical practice among all trainees is related to significant financial costs and complexity.
 A new effectiveness evaluation method of LIS simulation training programs (the Method) has been suggested. It is aimed at evaluating the total amount of results and other ST effects, as well as analyzing individual factors that can influence training results. The Method includes a survey among ST participants. It has been applied to effectiveness evaluation of LIS simulation training program at Educational and Accreditation Center of the Botkin City Clinical Hospital. The survey showed that 88.9% of surgeons attending the LIS training program implemented their knowledge into practice.
 The suggested Method allows to evaluate the effectiveness of LIS simulation training and its implementation into practice among all trainees, analyze factors that can influence the training results and use the obtained results for further improvement of the training program and its methods. 
 The Method may be recommended for implementation at medical simulation training centers.

The main problems and defects of the medical care on prehospital stage for patients with acute cerebrovascular accident in Stavropol

The purpose of the study was to identify the care provision defects on prehospital stage in patients with stroke in order to improve the quality of care for this category of patients. Objectives of the research: to study the frequency of hospitalization the patients with suspected stroke, depending on gender and age; to evaluate the efficiency of the ambulance team’s departure to the patient and the timing of the patient’s delivery to the hospital; to assess the quality of diagnosis and drug therapy at the prehospital stage. Materials and methods. The analysis of statistical observation forms No. 30, form № 109/y, accounting form № 110/y Stavropol Regional Clinical Emergency Medical Station, as well as case histories of patients with stroke in City Clinical Hospital No. 3, Stavropol, from 2016 to 2020. Results. A retrospective analysis of accounting and statistical documents of the Ambulance in a five-year period showed a fairly high efficiency in the work of dispatchers – 74.3 % of correct interviewing of patients to identify risk categories; ambulance crew within the framework of efficiency indicators – the time to reach the specialized department in Stavropol was 44 ± 4.1 minutes. However, the analysis of case histories of the ICU revealed violations in the observance of the algorithm for providing medical care to patients with stroke, in the form of: lack of protection of the upper respiratory tract and maintenance of adequate oxygenation — 43 cases (93.4 %); poorly correctable OSHF at the prehospital stage — 12 cases (14.5 %); non-compliance with the algorithm for examining a patient with stroke at the prehospital stage – 11 (13.2 %); lack of provision of adequate venous access – 9 (10.8 %) cases. Conclusion. The revealed defects of the prehospital stage contributed to the worsening of acute cerebral insufficiency, changes in the volume of the lesion, increased dislocation of brain structures, and in some cases led to daily mortality.

Correlation between type 2 diabetes mellitus and pancreatic steatosis

Objective. To study the features of endocrine function in non-alcoholic fatty disease of the pancreas in patients with chronic pancreatitis in remission.
 Materials and methods. There were examined 62 patients with chronic pancreatitis without exacerbation, who were admitted to the day hospital department of the City Clinical Hospital № 9 (Izhevsk). The data of laboratory and instrumental research methods, the features of the pancreatic endocrine function in patients with chronic pancreatitis, accompanied by fatty degeneration of the organ were analyzed.
 Results. Pancreatic steatosis was detected in 80.8 % of cases in patients with chronic pancreatitis in remission with metabolically complicated obesity. Violation of endocrine function was diagnosed in 19.3 % of cases. In the presence of insulin resistance, 6 (16.7 %) of the examined patients were diagnosed type 2 diabetes for the first time. At high insulin levels, 4 (6.5 %) patients had no changes in the indicators of fasting sugar.
 Conclusions. All patients with increased insulin resistance and metabolically complicated obesity require a comprehensive clinical and laboratory-instrumental study for the early detection of non-alcoholic fatty pancreatic disease. When establishing the signs of fatty degeneration of the pancreas, dispensary observation as well as prophylactic and therapeutic measures are necessary to prevent the development of type 2 diabetes mellitus.

ЮВЕНИЛЬНАЯ ГРАНУЛЕЗОКЛЕТОЧНАЯ ОПУХОЛЬ ЯИЧНИКА У РЕБЕНКА: КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ И ОБЗОР ЛИТЕРАТУРЫ

Juvenile granulosa cell tumor of the ovaries is a rare disease in pediatric oncology. Mostly seen in girls and young women in premenarchal age (median age 10 y/o) and is more aggressive than the adult type, but has a favorable prognosis, especially in its early stages. Large reviews and studies include patients with bot adult and juvenile types granulosa cell tumor. Due to the limited cohort of pediatric patients, there are no standards for the treatment of juvenile granulosa cell tumor in pediatric practice. Therefore, diagnosis, treatment, and long-term follow-up for this disease are based on recommendations for an adult cohort. Adjuvant chemotherapy as a curative option is used in advanced stages above the FIGO IC. For the IC stage, the issue of prescribing adjuvant chemotherapy remains debatable. Article represents analysis of the bibliographical data of the largest studies on the treatment of this disease as well as clinical case of a 15 y/o patient with juvenile granulosa cell tumor of the right ovary who had received complex treatment in the Oncological Department of the Morozov Children’s City Clinical Hospital (Moscow, Russia).

ЭТИОЛОГИЧЕСКИЕ И КЛИНИЧЕСКИЕ ОСОБЕННОСТИ АНАФИЛАКТИЧЕСКОГО ШОКА У ПАЦИЕНТОВ, ГОСПИТАЛИЗИРОВАННЫХ В КЛИНИКУ ЭКСТРЕННОЙ МЕДИЦИНЫ

Introduction. Anaphylaxis is a severe generalized hypersensitivity reaction affecting more than one organ system that can start very quickly and symptoms can be severe or life-threatening. The profile of triggers and cofactors for anaphylaxis is age dependent and varies across geographies. The clinical manifestations of anaphylaxis are diverse, one of its most severe clinical phenotypes is anaphylactic shock. Aim. To assess the significance of various groups of triggers, cofactors and clinical features of anaphylactic shock in patients hospitalized in the Department of Allergology and Immunology of the Kazan City Clinical Hospital No. 7. Material and methods. A retrospective analysis of 107 medical records of inpatients hospitalized in the Department of Allergology and Immunology of City Clinical Hospital No. 7 with a diagnosis of anaphylactic shock (T78.0, T78.2, T80.5, T88.6) was carried out for three calendar years (from 01.01.2018 to 31.12.2020). Statistical data processing was carried out using the Statistical Package for Social Sciences (v.18.0). Results and discussion. It has been shown that medicines were the most common trigger for anaphylactic shock in hospitalized patients, while food and insect bites led to the development of shock much less frequently and with approximately the same frequency. The vast majority of patients did not have concomitant diseases, and also did not take concomitant therapy, which are risk factors for the severe course of anaphylaxis. Skin changes were the most frequent symptom, supplementing the clinic of anaphylactic shock, followed, approximately with equal frequency, by gastrointestinal and respiratory symptoms, neurological symptoms were most rarely recorded. Conclusion. To verify the trigger as the cause of anaphylactic shock, it is necessary to conduct an allergological examination after the resolution of its symptoms. To assess the influence of exogenous and endogenous cofactors on the occurrence of anaphylaxis and the severity of its course, it is necessary to conduct prospective studies.

ЮВЕНИЛЬНАЯ ГРАНУЛЕЗОКЛЕТОЧНАЯ ОПУХОЛЬ ЯИЧНИКА У РЕБЕНКА: КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ И ОБЗОР ЛИТЕРАТУРЫ

Juvenile granulosa cell tumor of the ovaries is a rare disease in pediatric oncology. Mostly seen in girls and young women in premenarchal age (median age 10 y/o) and is more aggressive than the adult type, but has a favorable prognosis, especially in its early stages. Large reviews and studies include patients with bot adult and juvenile types granulosa cell tumor. Due to the limited cohort of pediatric patients, there are no standards for the treatment of juvenile granulosa cell tumor in pediatric practice. Therefore, diagnosis, treatment, and long-term follow-up for this disease are based on recommendations for an adult cohort. Adjuvant chemotherapy as a curative option is used in advanced stages above the FIGO IC. For the IC stage, the issue of prescribing adjuvant chemotherapy remains debatable. Article represents analysis of the bibliographical data of the largest studies on the treatment of this disease as well as clinical case of a 15 y/o patient with juvenile granulosa cell tumor of the right ovary who had received complex treatment in the Oncological Department of the Morozov Children’s City Clinical Hospital (Moscow, Russia).

ОПЫТ ПРИМЕНЕНИЯ ИММУНОТЕРАПИИ АНТИ-GD2 МОНОКЛОНАЛЬНЫМИ АНТИТЕЛАМИ У ПАЦИЕНТОВ С НЕЙРОБЛАСТОМОЙ ГРУППЫ ВЫСОКОГО РИСКА В АМБУЛАТОРНЫХ УСЛОВИЯХ

Neuroblastoma (NB) is the most common extracranial solid tumor in childhood. Prior to the introduction of intensive multimodal therapy, overall survival (OS) in patients with high-risk NB was below 15%. The addition of immunotherapy with dinutuximab beta in post-consolidation to multimodal treatment can increase the 5-year event-free survival rate for patients with high-risk NB up to 56.6%, and the 5-year OS up to 73.2%. The purpose of the research was to study the efficacy and safety of dinutuximab beta therapy in high-risk NB patients. Materials and methods used: the study included 8 pediatric patients with high-risk NB who had been treated with dinutuximab beta immunotherapy during postconsolidation on the basis of the Morozov Children’s City Clinical Hospital (Moscow, Russia) in 2020 to 2022. In case a patient's vital parameters normalization coupled with the absence of the need for accompanying therapy for 24 hours in a hospital, the patient was then considered as a candidate for outpatient treatment with possible no need for admission in the hospital. Results: 6 patients (75%) completed the full course of therapy with dinutuximab beta. The course of immunotherapy was not completed in 2 patients due to further progression of the disease. The most common adverse events were recorded as follows: pain (100%), fever (100%), diarrhea (62.5%), edematous syndrome (37.5%), allergic reactions (25%), hematological toxicity (25%). The period of time to becoming the candidates for outpatient treatment was 10.38±2.56 days for the 1st cycle of therapy and 2.67±1.63 days for the last, 5th cycle of the immunotherapy. In 6 out of 8 cases described the immunotherapy with dinutuximab beta allowed maintaining the response to treatment achieved after the end of consolidation preventing further development of the disease. The overall good tolerance to the drug made it possible to carry out the immunotherapy on an outpatient basis using microinfusing pump. Conclusion: an adequate route of administration and accompanying treatment make dinutuximab beta toxicity profile sufficient for outpatient management of patients with high-risk NB.

ОПЫТ ПРИМЕНЕНИЯ ИММУНОТЕРАПИИ АНТИ-GD2 МОНОКЛОНАЛЬНЫМИ АНТИТЕЛАМИ У ПАЦИЕНТОВ С НЕЙРОБЛАСТОМОЙ ГРУППЫ ВЫСОКОГО РИСКА В АМБУЛАТОРНЫХ УСЛОВИЯХ

Neuroblastoma (NB) is the most common extracranial solid tumor in childhood. Prior to the introduction of intensive multimodal therapy, overall survival (OS) in patients with high-risk NB was below 15%. The addition of immunotherapy with dinutuximab beta in post-consolidation to multimodal treatment can increase the 5-year event-free survival rate for patients with high-risk NB up to 56.6%, and the 5-year OS up to 73.2%. The purpose of the research was to study the efficacy and safety of dinutuximab beta therapy in high-risk NB patients. Materials and methods used: the study included 8 pediatric patients with high-risk NB who had been treated with dinutuximab beta immunotherapy during postconsolidation on the basis of the Morozov Children’s City Clinical Hospital (Moscow, Russia) in 2020 to 2022. In case a patient's vital parameters normalization coupled with the absence of the need for accompanying therapy for 24 hours in a hospital, the patient was then considered as a candidate for outpatient treatment with possible no need for admission in the hospital. Results: 6 patients (75%) completed the full course of therapy with dinutuximab beta. The course of immunotherapy was not completed in 2 patients due to further progression of the disease. The most common adverse events were recorded as follows: pain (100%), fever (100%), diarrhea (62.5%), edematous syndrome (37.5%), allergic reactions (25%), hematological toxicity (25%). The period of time to becoming the candidates for outpatient treatment was 10.38±2.56 days for the 1st cycle of therapy and 2.67±1.63 days for the last, 5th cycle of the immunotherapy. In 6 out of 8 cases described the immunotherapy with dinutuximab beta allowed maintaining the response to treatment achieved after the end of consolidation preventing further development of the disease. The overall good tolerance to the drug made it possible to carry out the immunotherapy on an outpatient basis using microinfusing pump. Conclusion: an adequate route of administration and accompanying treatment make dinutuximab beta toxicity profile sufficient for outpatient management of patients with high-risk NB.

Наш опыт организационных мероприятий по обеспечению функционирования крупной офтальмологической клиники в период пандемии COVID-19

Purpose. To analyze changes in work of the Khabarovsk branch of the S. Fyodorov Eye Microsurgery Federal State Institution (the Khabarovsk branch) caused by combination of elective and emergency ophthalmic care in the context of a pandemic of the novel coronavirus disease (COVID-19). Material and methods. The article presents the organizational restructuring of activities medical units of the Khabarovsk branch, due to need for additional performance of functions emergency ophthalmological service in connection with closure of the regional ophthalmological center of City Clinical Hospital named after Professor A.M. Voyno-Yasenetsky, which previously performed this function. Complex of organizational anti-epidemic measures taken to prevent the spread of COVID-19 in pandemic is presented, their feasibility is analyzed, the results of the clinic's activities in new conditions of the COVID-19 pandemic are reflected. Results. The COVID-19 epidemic required a significant organizational restructuring of the Khabarovsk branch. In addition to large volumes of elective surgery, emergency ophthalmosurgical care was added, performed in a round-theclock hospital. All this was superimposed on the organizational restructuring of patient flows, created to minimize their interpersonal contacts. Conclusions. The Khabarovsk branch fully coped with the tasks set, stable work was organized in the new pandemic conditions, effectively combining planned and emergency algorithms of ophthalmic surgical care. The measures taken made it possible to provide emergency ophthalmic care in full throughout the entire period of the epidemic, to resume the provision of planned ophthalmic care in full, without compromising the safety of patients' stay in the clinic. Keywords: COVID-19; SARS-CoV-2, pandemic, emergency care, eye emergency department, Eye casualty, coronavirus disease, organization of medical care

REHABILITATION MEASURES IN THE PALLIATIVE DEPARTMENT, CLINICAL CASE OF A PATIENT AFTER COVID-19

Covid-19 is an infectious disease caused by the SARS-CoV-2 virus. It is a pandemic acute respiratory illness. The virus spreads and is transmitted through the mouth or nose drops of an infected person, while talking, coughing, sneezing, and more likely in crowded places. By breathing in respiratory droplets or small particles, a healthy person has a high risk of infection. The disease is experienced in different ways, from the onset of slight malaise to recovery, and from a severe course of the disease, the consequences arising from the viral infection, which do not do without the help of doctors. Objective. To study a clinical case of a patient after Covid-19. Material of investigation was the clinical case of a 61-year-old woman, admitted after 40 days of resuscitation to the Palliative Department, Kyiv City Clinical Hospital № 6. Methods of investigation: history of the patient after Covid-19, collection of anamnesis, laboratory and clinical methods of examination. The multidisciplinary team headed by the head of the palliative department was created. We used all possible rehabilitative measures to achieve the set objectives successfully. Results. The patient received the full range of diagnostic and rehabilitative measures. After the end of treatment and rehabilitation measures, the follow-up observation by the family doctor was recommended, it testifies to the successful improvement of the patient's functional state. Conclusion. The article presents my own experience, and introduction of the patient after Covid-19 in the Palliative Department, Kyiv City Clinical Hospital № 6. Individual approach and cohesion of the multidisciplinary team help to fulfill the patient's needs to the fullest extent. The important practical questions of rehabilitation measures for patients with the consequences of Covid-19 are considered.

Role of chest computed tomography in the diagnosis of SARS-CoV-2 pneumonia in children

Background: First PCR-confirmed COVID-19 cases among Russian children were reported in early March 2020. Chest computed tomography (CT) is the most sensitive imaging modality in diagnosing early signs of viral lung damage. Limited data are available on clinical and laboratory features of COVID-19 in children and on their correlation with imaging findings. Studying COVID-19 features in children is crucial for modern medicine, which makes our research relevant.Objective: To determine the diagnostic efficacy and correlation between laboratory, clinical, and CT findings in children and adolescents with COVID-19.Materials and methods: From February 2020 to February 2021 372 patients with suspected COVID-19 were admitted to Morozov Children’s City Clinical Hospital (Moscow, Russian Federation). This retrospective study included 158 patients who presented with positive oropharyngeal and nasopharyngeal swab results, IgM and IgG test results, changes in complete blood count, blood biochemistry and coagulation test results, clinical symptoms, and suspected SARS-CoV-2 pneumonia based on chest CT findings.Results: Chest CT sensitivity and specificity for diagnosis of SARS-CoV-2 pneumonia were up to 98% and 85%, respectively. We considered that severe respiratory motion artifacts in young children under general anesthesia adversely affected the diagnostic efficacy. Sensitivity and specificity in this group were up to 89% and 71%, respectively.Conclusions: Viral pneumonia signs on chest CT scans were statistically significantly more frequent in children with cough, respiratory failure signs, lymphopenia, and increased D-dimer and C-reactive protein levels. One of these signs or a combination of them are an indication for chest CT in children with suspected SARS-CoV-2 pneumonia.

Transfistula antegrade interventions in the treatment of benign biliary strictures

Background. Primary reconstructive operations aimed at restoring the passage of bile are rather complicated due to the cicatricial process and in 1530% lead to a distant recurrence of the disease.
 Aim. To present the results of combined X-ray surgery and endoscopic transfistula antegrade interventions in the treatment of benign bile duct strictures.
 Material and methods. For the period from 2011 to 2019 31 patients with benign bile duct strictures were treated in the surgical departments of the City Clinical Hospital No. 14 in Yekaterinburg. The mean age of the patients was 60.312.7 years, the comorbidity index was 2.6. As follows from the presented data, in 13 patients the stricture developed in the area of biliodigestive anastomoses. Another 17 patients had stricture after surgery for cholelithiasis. In 1 case, there was a persistent narrowing of the lumen of the choledochus against the background of indurative pancreatitis. In 25 (80.6%) cases, the first step was percutaneous transhepatic cholangiostomy under ultrasound guidance. Another 6 (19.4%) patients had a T-shaped drainage of the choledochus.
 Results. For the treatment of strictures of the bile ducts, 97 operations were performed: an average of 3.1 operations per 1 patient. Lithoextraction with a wire basket was performed in 17 patients with calculi. 5 patients with stones larger than 10 mm required contact lithotripsy. Stricture was confirmed in 25 patients. Balloon dilatation was performed in 21 cases. In 8 cases, dilatation was supplemented with papillosphincterotomy. In 6 patients with deformation of the anastomosis zone, framed drainage was installed for 12 months. In 3 patients, bilioduodenal stenting with a nitinol stent was performed. It was not possible to recanalize the stricture in 4 (13%) cases. Complications were registered in 1 (3.2%) patient (IIIB degree according to ClavienDindo).
 Conclusion. Transfistula cholangioscopy is an effective endoscopic technology in the treatment of patients with benign bile duct strictures.

Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty.

Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy, designed to reduce the disability period and improve the medical care quality. The study aims to analyze the enhanced recovery protocol effectiveness in a comparative study of elective urethral stricture surgery. A prospective study included 54 patients with an established diagnosis of urethral stricture in 2019-2020 in the urological hospital of the Irkutsk City Clinical Hospital No. 1. All 54 patients have completed the study. There were two groups of patients FTS-group (group II, n = 25) and standard group (group I, n = 29). In terms of preoperative parameters, the comparison groups have statistical homogeneity. The comparative intergroup efficacy analysis of the treatment based on the criteria established in the study demonstrated good treatment results for 5 (17.2%) patients of group I and 20 (80%) patients of group II (p=0.004). The overall efficacy of urethroplasty surgeries, regardless of the treatment protocol, was comparable (86.2% vs 92%; p=0.870), as well as the likelihood of relapse within two years (p=0.512). The predictors of recurrence were technical complications and urethral suture failure (OR 4.36; 95% CI 1.6; 7.11; p=0.002). The FTS protocol reduced the treatment period (p < 0.001) and decreased the severity of postoperative pain (p < 0.001). The use of the "fast track surgery" protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization.

Фібриляція передсердь як прогностичний фактор у пацієнтів з тромбоемболією легеневої артерії

Мета роботи – проаналізувати особливості клінічного перебігу та визначення прогностичних критеріїв у пацієнтів з тромбоемболією легеневої артерії (ТЕЛА) та супутньою фібриляцією передсердь (ФП).Матеріали і методи. Проведено ретроспективний аналіз 243 медичних карток стаціонарних пацієнтів з діагнозом «ТЕЛА», що були послідовно госпіталізовані до КНП «МКЛ № 8» ХМР у період з 01.01.2018 до 01.01.2020. Критерій залучення – діагноз «ТЕЛА», верифікований мультиспіральною комп’ютерною томографічною ангіогра­­фією (МСКТ-ангіографія) легеневих судин та/або за результатами автопсії. Хворі були розподілені на групи: 1 – 45 (18,5 %) пацієнтів з ТЕЛА і ФП, 2 – 198 (81,5 %) пацієнтів з ТЕЛА без ФП. Пацієнти групи 1 були розподілені на підгрупи: 1А – 22 (48,8 %) хворих з ТЕЛА і ФП de novo; 1Б – 23 (51,2 %) хворих з ТЕЛА і ФП, що була наявна до епізоду гострої ТЕЛА. Проаналізовано клініко-анамнестичні, лабораторно-інструментальні параметри, рівні летальності, проведено статистичний аналіз даних.Результати та обговорення. Пацієнти з групи 1 були старшими (відповідно (67,2±10,6) і (58,6±14,6) року), мали більше випадків ішемічного інсульту в анамнезі. Під час госпіталізації пацієнтів з високим ризиком було більше в групі 1; у хворих з невисоким ризиком за індексом PESI було більше балів, вони мали нижчу сатурацію крові, більшу частоту серцевих скорочень. За лабораторними показниками групи відрізнялися за рівнем нейтрофілів та креатиніну. За даними МСКТ-ангіографії легеневої артерії (ЛА) групи відрізнялися за розмірами легеневого стовбура, діаметрами легеневих артерій; за даними ехокардіографії – за розмірами лівого та правого передсердь, кінцеводіастолічним і кінцевосистолічним розмірами лівого шлуночка (ЛШ), фракцією викиду ЛШ, середнім тиском у ЛА. При порівнянні груп 1А та 1Б була виявлена різниця щодо кількості ішемічних інсультів (більше в групі 1Б). Значна частина хворих з групи 1А були з високим ризиком, крім того, пацієнти обох груп мали великі індекси за шкалою PESI. За лабораторними показниками групи статистично значуще відрізнялися за рівнем нейтрофілів та креатиніну. Розмір лівого передсердя був статистично значуще більшим у групі 1Б, проте середній тиск у ЛА був вищим у групі 1А. Загальна летальність становила 18,5 %, летальність в осіб без ФП та з ФП суттєво відрізнялася (відповідно 13,6 і 44,4 %). Статистично значуща різниця також спостерігалася за рівнем летальності в групах 1А та 1Б (відповідно 67,5 і 21,7 %). За даними уні- та мультиваріантного аналізу визначено фактори, що впливають на прогноз, зокрема ФП.Висновки. У хворих з ТЕЛА ФП трапляється у 18,5 %, а у 9 % – уперше діагностована. Хворі з ФП і ТЕЛА в середньому були старшими за хворих з ТЕЛА без ФП на 8,6 року. У групі хворих з ФП рідше виявляють тромбоз вен нижніх кінцівок. У хворих з ФП статистично значуще більші розміри не тільки лівого, а й правого передсердя та нижча ФВ ЛШ. ФП, як і вік, сатурація крові киснем, наявність ожиріння, кількість балів за індексом PESI, є незалежним чинником, що пов’язаний з несприятливим прогнозом (госпітальною летальністю). За результатами моделі Каплана – Мейєра, найбільш виразний негативний вплив на найближчий прогноз має вперше діагностована ФП.

Long-Term Functional Consequences of Treatment of Fractures of the Distal Metaepiphysis of the Radius

Summary. The frequency of damage to the distal metaepiphysis of the radius reaches from 16% to 33% of all fractures of the bones of the skeleton, and the increase in the incidence of osteoporosis definitely maintains the tendency to increase the frequency of damage to this localization. About 53.3% of the injured need repositioning; half of them (26.6%) have large unstable fractures of type B and C, which are subject to surgical treatment.&#x0D; Materials and Methods. The study was carried out based on the materials of the trauma centers and trauma departments of the “City Clinical Hospital No. 2” of the DCC (Dnipro) and the MNPE “City Clinical Hospital No. 6” of the DCC (Dnipro). To assess the long-term consequences, a retrospective analysis of archive records of 318 patients with damage to the distal metaepiphysis of the radius was performed, including 271 radiographs of females (85.2%) and 47 males (14.8%).&#x0D; Results. The conducted analysis gives grounds to state that remote manifestations depend on the nature and severity of fractures, the quality of reposition or surgical treatment. Fractures of type A and C have a pronounced tendency to develop manifestations of deforming arthrosis of the radiocarpal joint in the remote period after the injury, which may be due to the presence of incongruity of the articular surfaces against the background of residual “permissible” displacements of the fragments.&#x0D; Conclusions. Ensuring accurate repositioning of fractures and expanding the indications for surgical treatment in case of “permissible” displacement of bone fragments in fractures of the distal metaepiphysis of the radial bone will reduce the frequency and severity of arthrosis in the remote period after the injury.

Modern treatment management strategy for inflammatory bowel diseases

MODERN TREATMENT MANAGEMENT STRATEGY FOR INFLAMMATORY BOWEL DISEASES Olexander I. Poida1, Volodymyr M. Melnyk1, Mykola D. Kucher1, Tetiana G. Kravchenko1, Myroslav I. Kryvoruk2 1 O. O. Bogomolets National Medical University, Taras Shevchenko Boulevard, 13, Kyiv 01601, Ukraine 2 UNCE (Utility non-commercial enterprise) «Kyiv City Clinical Hospital №18», Taras Shevchenko Boulevard, 13, Kyiv 01601, Ukraine Introduction. Enrichment of knowledge in etiology and pathogenesis, improvement of existing and development of new methods and technologies, strategies and tactics for IBD will contribute to improving the results of their diagnosis and treatment. The aims. To improve the treatment results of patients with IBD by developing and implementing modern treatment management strategies for their diagnosis and treatment. Material and methods: The modern diagnostic and treatment management of IBD has been developed and put into practice. It provides for the improvement of diagnosis and differential diagnosis of diseases, justification and selection of the optimal personalized method of treatment, depending on the characteristics of the clinical course, the severity of the patient's condition, and the existing risk of complications. Results. From 2013 to 2022, 1340 patients, 732 (54.6 %) men and 608 (45.4 %) women with IBD were treated at the Coloproctology Center of Ukraine. There were 812 (60.6 %) patients with ulcerative colitis and 528 (39.4 %) with CD. Conservative therapy received 1107 (82.6 %) patients, and surgical treatment – 233 (17.4 %). Postoperative complications occurred in 37 (15.9 %) patients, and deaths – were in 5 (2.1 %). All patients in the conservative treatment group had positive therapeutic dynamics, and improvement of morphological changes in the intestinal mucosa according to the control colonoscopy and biopsy. Positive functional results and life quality improvement were obtained in most patients after surgical treatment. Conclusion. 1. Conservative treatment involves the use of modern and highly effective drugs that can modify the course of IBD and thus prevent complications. 2. The choice of surgical strategy and treatment tactics is reasonable in the presence of a high risk of adverse course of UC and CD, as well as the development of complications that pose a threat to the patient's life. 3. Implementation of the proven treatment management for inflammatory bowel disease allowed: to increase to 82.6 % the number of patients who are indicated conservative therapy and reduce the risk of recurrence of these diseases; to decrease the number of surgical interventions to 17.4 %, increase the performance of surgical interventions according to relative indications to 62.5 %, even before the occurrence of severe complications of diseases; reduce the incidence of postoperative complications to 15.9 %, postoperative mortality to 2.1 %, and improve functional outcomes and quality of life of operated patients. Keywords: bowel, inflammatory diseases, diagnosis, treatment.

Prediction of adenomyosis in patients with uterine fibroids

Aim. To determine the clinical, anamnestic, and immunological predictors of adenomyosis by developing a prognostic model of uterine fibroids with concomitant adenomyosis.&#x0D; Materials and methods. A retrospective single-center study was conducted at Kurbatov Novokuznetsk City Clinical Hospital №1, from 2012 to 2019. The model included 284 women with histologically confirmed uterine fibroids, of which 34.9% (99/284) were fibroids with adenomyosis and 65.1% (185/284) were isolated uterine fibroids. Logistic regression was used to develop the mathematical model.&#x0D; Results. Predictors of adenomyosis in patients with uterine fibroids have been established: age 43 years and older, concomitant endometrial hyperplasia, chronic inflammatory diseases of the cervix, menometrorrhagia, history of childbirth, history of endometrial disorders, varicose veins of the lower extremities, history of appendectomy, blood serum lactoferrin of more than 1.8 mg/L, interleukin-6 levels more than 2.8 pg/mL. The model has an accuracy of 91%, a sensitivity of 90%, a specificity of 92%, a positive predictive value of 85%, and a negative predictive value of 94%.&#x0D; Conclusion. The established predictors of adenomyosis allow for predicting the risk of adenomyosis in patients with uterine fibroids, facilitating effective treatment choices.

Multimodal approach to pain management in thoracic surgery

The American Cancer Society estimated that 68,820,000 men and 61,360,000 women in the United States of America would die from lung and bronchial cancer in 2022, which is equal to 21% of all cancer deaths. Patients who undergo thoracotomy have a higher risk of postoperative complications due to the severe pain syndrome that typically develops after surgery. Even though there has been extensive research on the advantages and disadvantages of various perioperative analgesia techniques, the search for the best and safest still continues.&#x0D; Objective — to improve the results of perioperative anesthesia in patients undergoing thoracotomy by choosing the optimal method of analgesia.&#x0D; Materials and methods. A total of 59 patients with lung cancer who underwent thoracotomy at the communal non‑profit enterprise «Kyiv City Clinical Hospital No 17» from 2018 to 2020 were included in an open‑label noncommercial randomized controlled clinical trial. Patients were divided into 2 groups: the multimodal analgesia (MA) group (32 patients) and the epidural analgesia (EA) group (27 patients). According to the concept of preemptive analgesia, patients in the MA group received 1000 mg of paracetamol and 50 mg of dexketoprofen intravenously 1 hour before surgery. In the postoperative period, dexketoprofen and paracetamol were administered every 8 hours in combination with epidural analgesia. During postoperative epidural analgesia, patients received 40 mg of a 2% lidocaine solution through a catheter inserted into the epidural space (Th5—Th6) and a ropivacaine 2 mg/mL (3—14 mL/h) infusion. Patients in the EA group received only epidural analgesia in the postoperative period. After placement of an epidural catheter in the epidural space (Th5—Th6), they had an injection of 40 mg of a 2% lidocaine solution and an epidural infusion of ropivacaine 2 mg/ml (3—14 mL/h).&#x0D; Results. The study groups did not demonstrate a statistically significant difference in terms of age, hight, weight, a grade of anesthesiological risk (ASA), blood loss, surgery duration, and surgical volume (р &gt;0,05). The level of analgesia was assessed using the numerological rating scale (NRS) after 3, 6, 24, and 32 hours after surgery. Every research stage revealed a significant difference in the level of pain syndrome between the study groups (p&lt;0.05). Patients in the EA group experienced more severe pain syndrome than those in the MA group. Consequently, 7 patients (26%) in the EA group were anesthetized with morphine 10 mg intramuscularly compared to 3 patients (9%) in the MA group.&#x0D; Conclusions. In patients undergoing thoracic surgery, a multimodal analgesic approach, which includes the use of COX‑2 and COX‑3 inhibitors in combination with epidural analgesia, has been shown to produce better analgesia compared to epidural anesthesia alone. The beneficial effect of multimodal analgesia was seen in a significant difference (p&lt;0.05) in the intensity of pain syndrome between the study groups in the early postoperative period after thoracotomy.