Sklifosovsky Research Institute Research Articles

Prosthetic repair of the anterior abdominal wall in patients after solid organ transplantation: The experience of N.V. Sklifosovsky Research Institute for Emergency Medicine

Rationale. The postoperative ventral hernia is seen in 1.6-34.8% of patients undergoing organ transplantation that determines the urgency of this problem. The objective was to improve the treatment of patients with postoperative ventral hernia after organ transplantation. Material and methods. From 2006 to 2017, 36 patients underwent surgery with synthetic material application for postoperative ventral hernias after organ transplantation. There were 15 women (41.7%) and 21 men (58.3 %). The median age was 55 years [44.5; 59]; the median body mass index was 30 kg/m2 [27.1; 33.2]. Results. The postoperative period was uneventful in 13 patients (36.1%). Twenty three patients (63.9%) developed complications of varied severity, including 13 patients (56.5%), in whom the revealed complications were not considered the indications to a targeted therapy (Category I), 3 patients (13.1%) in whom the complications regressed after the drug therapy had been corrected (category II), 7 (30.4%) patients in whom complications were cured using mini-invasive surgical techniques (category IIIa). Conclusions. The prosthetic hernia repair demonstrated a high efficacy and safety as the treatment for postoperative ventral hernia in patients after solid organ transplantation.

Клинико-психологические особенности аддиктов с незавершенными суицидальными попытками

The article presents results of social, psychological and clinical aspects of suicidal behaviour of alcohol addicts and drug addicts with incomplete suicide attempts, admitted to the Department of crisis states and psychosomatic disorders, Sklifosovsky Research Institute of Ambulance Service from November 2014 to June 2015. The majority of addicts (70%) showed an affective kind of suicidal actions. During an acute post-suicidal period all examined patients revealed value-oriented approach to life. Conflict becomes irrelevant as a result of expressed fear of death and fear of social and transcendental consequences of an suicide act. Alcohol addicts feel guilty towards relatives and others, and need of their support. They have significantly increased fear to loss of social identity. Drug addicts have maintained negative view of near and distant future events, they consider the act of suicide as an effective and radical way of solving life problems. Based on our findings we concluded that the risk of repeat suicide attempts in patients with alcohol dependence can be caused by the weakness of self-management skills and lack of microsocial environmental support, while a similar risk in persons with drug addiction can be due to negative view of their own future and the degree of social maladjustment.

Time Course of Changes in the Level of Procalcitonin in the Development of Nosocomial Pneumonia in Victims with Severe Concomitant Injury in an Intensive Care Unit

Background. The posttraumatic period in victims with severe concomitant injury is frequently complicated by nosocomial pneumonia, resulting in high mortality rates and longer time and increased cost of treatment in intensive care unit unit patients. Procalcitonin (PCT) is considered to be a marker for infectious complications due to different critical conditions; however, its prognostic value for different patient categories and periods after injury remains unclear; elevated PCT levels maybe related to the development of pneumonia in view of the severity of injury and the duration of mechanical ventilation (MV). Objective: to establish a correlation between the time course of changes in PCT levels and the development of nosocomial pneumonia and sepsis in victims with severe concomitant injury in relation to its severity and the duration of MV. Subjects and methods. The case histories of 271 victims with severe concomitant injury treated in the Intensive Care Unit, N. V. Sklifosovsky Research Institute of Emergency Care, in 2008—2012 were retro- and prospectively analyzed. The admission PCT level and its changes were analyzed in relation to the severity of injury and secondary infectious complications. Severe concomitant injury was ascertained to be accompanied by elevated serum PCT levels. A correlation was found between injury severity, mortality, the development of infectious pulmonary complications, sepsis, and mean PCT levels. The more severe the injury, the higher serum PCT level was revealed. In the first 12 hours, a group of victims without pneumonia exhibited the highest PCT levels (1.91±0.51 ng/ml). Later on there was its smooth fall and normalization by days 3—5. In the group of victims with pneumonia, but without sepsis, the PCT level averaged 1.71±0.64 ng/ml just in the first 6 hours, then its concentration continued to rise and its maximum level (3.93±1.26 ng/ml) was recorded in the first 48 hours. Later on, its decrease and normalization were observed by day 6 if the course of disease was favorable. A distinct pattern was seen in the group of victims with pneumonia and sepsis. Just in the first 6 hours, the mean level of PCT was 6.98±1.3 ng/ml and then its concentration continued to increase to 22.7±7.8 ng/ml in the first 48 hours. ROC analysis revealed the most prognostic effect of PCT at risk for pneumonia in the range from 12 to 24 hours since the ROC curve area was 0.753, which was good, as estimated by experts, and the cut-off was 1.79 ng/ml; moreover, sensitivity was 69.7% and specificity was also 69.7%. Conclusion. It is shown that it is expedient to monitor PCT levels in patients with severe concomitant injury from the admission of victims to hospital. The PCT concentration of more than 1.79 ng/ml during the first 12 hours after injury can serve as an early predictor for nosocomial pneumonia with a risk for further generalization of the process in victims with severe concomitant injury. Key words: severe concomitant injury, procalcitonin, infectious complications, pneumonia, sepsis, biomarker, predictor, mortality, ISS, mechanical ventilation.

Defenses Against the Fear of Death in Postsuicide

This study explores the attitudes about death in normal people (n = 156) and patients after recent suicide attempt (n = 185). The group of patients was taken from the department of toxicology at the N. V. Sklifosovsky Research Institute of Emergency Medicine. We view the suicidal act as a mortality salience and hypothesize that those who deny their recent suicide attempt (n = 43) and who have one (n = 105) or several (n = 37) suicide attempts in their personal history exhibit different terror-management patterns in comparison with each other and with the control group. They fall back on different resources with various degrees of effectiveness. Implications of these results for understanding suicidal and postsuicidal behavior are discussed and suggestions for rehabilitation are made.

Applications of the Endoscopic Treatment in Cranioorbital Trauma

Materials and Methods: During the period from August 1, 2011 to December 30, 2011, in the N.V. Sklifosovsky Research Institute of Emergency Medical Care, 5 patients with isolated outer table frontal sinus fracture and 11 patients with sphenoid sinus fractures and cerebrospinal fluid (CSF) leakage were treated by the endoscopic approach. In the former group, to reach depressed fragments, a 7-cm horizontal skin incision was placed 1.5 cm behind the hairline in the central plane. A rigid 4-mm, 30° endoscope with elevators was used to expose the defect in a subperiosteal plane. To repair frontal sinus fracture, we used thin (0.3 mm) titanium microplates, which were rigidly fixated by percutaneously placed 5-mm screws. Transnasal closure of sphenoid defect with 4-mm, 0° and 30° endoscopes was achieved with muscle, mucosa of middle nasal concha, or in combination with DuraSeal.

ALGORITHMS FOR DIAGNOSIS AND TREATMENT OF PATIENTS WITH CONCOMITANT SPINE AND SPINAL CORD INJURY

Objective. Representation of the algorithm for diagnosis and choice of treatment approach in patients with damage to the spine and spinal cord in concomitant injury. Material and Methods. Data of complex examination and surgical treatment of 514 patients with concomitant spine and spinal cord injury treated at the NV Sklifosovsky Research Institute of Emergency Care in 2000-2010 were analyzed. The control group included 373 patients with isolated spinal cord injury. Results. Based on the analysis of clinical data achieved in 2000-2003 the algorithms were developed and introduced to diagnose and treat patients with concomitant spine and spinal cord injury, which allowed reducing the number of complications by 2.5 times and deaths by 2.9 times. Risk factors in the acute period and during the operation were identified. Conclusion. Compliance with the algorithms of diagnosis and treatment of patients with concomitant spine and spinal cord injury has reduced the number of complications and deaths. Hir. Pozvonoc. 2012;(1):8-18.

ALGORITHMS FOR DIAGNOSIS AND TREATMENT OF PATIENTS WITH CONCOMITANT SPINE AND SPINAL CORD INJURY

Objective. Representation of the algorithm for diagnosis and choice of treatment approach in patients with damage to the spine and spinal cord in concomitant injury. Material and Methods. Data of complex examination and surgical treatment of 514 patients with concomitant spine and spinal cord injury treated at the NV Sklifosovsky Research Institute of Emergency Care in 2000-2010 were analyzed. The control group included 373 patients with isolated spinal cord injury. Results. Based on the analysis of clinical data achieved in 2000-2003 the algorithms were developed and introduced to diagnose and treat patients with concomitant spine and spinal cord injury, which allowed reducing the number of complications by 2.5 times and deaths by 2.9 times. Risk factors in the acute period and during the operation were identified. Conclusion. Compliance with the algorithms of diagnosis and treatment of patients with concomitant spine and spinal cord injury has reduced the number of complications and deaths.

Psychotherapy for patients with a response to severe stress and adaptive disorders at a hospital

The paper considers the issues of psychotherapy (PT) in patients showing a response to severe stress and adaptive disorders. The patients treated at the N.V. Sklifosovsky Research Institute of Emergency Care for burn injury and concomitant injury resulting from emergencies and road traffic accidents were examined. Psychopathological disorders were comparatively analyzed in the groups of patients depending on the genesis of psychological trauma. The authors consider the specific features of the clinical picture and propose a PT algorithm for these patients.

Rapid Evaluation of the Severity and Prognosis of Acute Carbon Monoxide Poisoning

Objective: to assess whether cardiointervalography (CIG) might be used to define the health status of patients with carbon monoxide poisoning. Subjects and methods. The autonomic nervous system (ANS) was studied in 114 patients aged 16 to 80 years with carbon monohydrate poisoning who were treated at the N. V. Sklifosovsky Research Institute of Emergency Care, Moscow, in 2004—2009. Cardiointervalographic readings were analyzed in relation to condition severity and disease outcome. Results. Within the first hours after carbon monoxide poisoning, the function of the ANS was found to be impaired, which was associated with the development of hypersym-pathicotonia caused by the increased activity of its sympathetic part and the decreased tone of the parasympathet-ic one. The magnitude of hypersympathicotonia depended on the severity of poisoning and the outcome of the disease. The preponderance of ANS parasympathetic part tone suggests disturbed adaptive and compensatory mechanisms and poor prognosis. Conclusion. Cardiointervalography is recommended for the objective evaluation of the severity of carbon monoxide poisoning and the efficiency of performed treatment and prediction of the outcome of the disease. Key words: carbon monoxide, autonomic nervous system, cardiointervalography, adaptive and compensatory mechanisms.

Changes in the Autonomic Nervous System in Patients with Carbon Monoxide Poisoning

Objective: to examine changes in the autonomic nervous system (ANS) function in patients with carbon monoxide poisoning in relation to the condition severity. Subjects and methods. The ANS was studied in 114 patients aged 15 to 82 years with carbon monohydrate poisoning who were treated at the N. V. Sklifosovsky Research Institute of Emergency Care, Moscow, in 2004—2008. Cardiointervalographic readings were analyzed in relation to the condition severity, the presence of thermal damages to the skin and upper airway, and that of blood alcohol. Results. Within the first hours after poisoning, the function of the ANS was found to be impaired, which was associated with the development of hypersympathicotonia caused by the increased activity of its sympathetic part and the decreased tone of the parasympathetic one. The magnitude of hypersympathicotonia depends on the severity of poisoning, on the presence of thermal damages to the upper respiratory tract and that of blood alcohol. The preponderance of the tone of the ANS parasympathetic part suggests the disturbance of adaptive and compensatory mechanisms and the likely poor prognosis of the poisoning. Conclusion. Cardiointervalography is recommended for the objective evaluation of the severity of carbon monoxide poisoning. Key words: carbon monoxide, autonomic nervous system, cardiointervalog-raphy, adaptive and compensatory mechanisms.

Changes in the Autonomic Nervous System in Patients Poisoned by Cauterizing Liquids

Objective: to examine changes in the function of the autonomic nervous system (ANS) in patients with intoxication with cauterizing liquids in relation to the condition of patients in order to early determine the prognosis of the disease. Subjects and methods. ANS was studied in 130 patients aged 15 to 82 years who had been poisoned by cauterants, treated at the Toxicological Unit, Voronezh Regional Hospital, and at the Center for Acute Intoxication Treatment, N. V. Sklifosovsky Research Institute of Emergency Care, Moscow, in 2004—2006. Cardiointervalographic parameters were analyzed in relation to the condition of patients, the time elapsed after intoxication prior to the patients’ admission to a specialized hospital, the presence of hemolysis and blood alcohol, the degree of upper gastrointestinal mucosal burn, and the pattern of poisoning (accidental or intentional). Results. Within the first hours after intoxication with cauterizing liquids, ANS was found to be impaired, which was associated with the development of hyper-sympathicotonia caused by the increased activity of its sympathetic part and the decreased tone of the parasympa-thetic one. The magnitude of hypersympathicotonia depends on the severity of poisoning, on the time elapsed after the onset of intoxication, on the presence of hemolysis, the blood content of alcohol, the degree of upper gastrointestinal burn, and the nature of poisoning. The preponderance of the tone of the ANS parasympathetic part suggests the disturbance of adaptive and compensatory mechanisms and a poor prognosis. Conclusion. Cardiointervalography is recommended for the objective evaluation of the severity of poisoning with cauterizing liquids and the efficiency of performed therapy and for the prediction of the outcome of the disease. Key words: cauterizing liquids, autonomic nervous system, cardiointervalography, adaptive and compensatory mechanisms.

Experience in Using the Factor Analysis of Laboratory Homeostatic Parameters in Patients Poisoned by Cauterizing Liquids

Objective: to use the factor analysis of laboratory and clinical signs in patients poisoned by cauterizing liquid to evaluate a response to chemical injury. Subjects and methods. The autonomic nervous system (ANS) was studied in 130 patients aged 15 to 82 years who were treated at the Toxicological Unit, Voronezh Regional Hospital, and at the Center for Acute Intoxication Treatment, N. V. Sklifosovsky Research Institute of Emergency Care, Moscow, for intoxication with cauterizing liquids. The parameters of general and biochemical blood analyses, the level of free plasma hemoglobin, and the blood and urinary concentrations of ethanol were analyzed. Results. The factorization of signs divided the symptom complex into 6 factors; the first four of them being of the greatest importance. Conclusion. The studies have indicated that an adequate ANS response is of initial and major value in the prediction of poisoning with cauterants. Key words: factor analysis, factorization of signs, cauterizing liquids, autonomic nervous system.

TREATMENT FOR COMPLICATED AND UNCOMPLICATED SPINE INJURIES IN MULTITRAUMA PATIENTS

Objective. To determine treatment tactics for spine and spinal cord injuries in multitrauma patients. Material and Methods. 184 patients with spine and spinal cord injuries combined with multiple traumas were treated at Sklifosovsky Clinical and Research Institute for Emergency Medicine in 2000–2003, out of them 141 patients underwent surgical treatment. Diagnostic algorithm included general and neurologic examinations, ultrasound studies of the abdominal and pleural cavities, radiography of the skull, pelvic, ribs, injured extremities and all spine levels, and spine myelography and CT. Patients were examined by resuscitator, neurosurgeon, traumatologist and surgeon. Hemodynamic and arterial blood characteristics were monitored in critically ill patients. To assess the severity of multiple trauma the ISS scoring system was used. Results. Single-stage operation in the spine and bones of the skeleton was performed in 13 patients, first-stage spine surgery (preceding another intervention) – in 39 patients, second-stage spine surgery – in 24 patients, and 65 patients underwent a spine surgery alone. Neurologic status improved in 60 patients. Total lethality was 22 % and postoperative one – 14 %. Conclusion. Direct relation between surgery outcome and severity of multiple trauma was reveled. Application of upto- date transpedicular and laminar fixation techniques, and halo-apparatus provides the possibility to perform twostage surgery for complicated unstable vertebral fractures in patients with severe trauma.