Treatment Tactics In Patients Research Articles

LIFE-THREATENING BURNS CAUSED BY HOUSEHOLD CHEMICALS

Background Chemical burns are 2.5 % to 5.1% of all burn injuries. Burns caused with household chemicals occur even more rarely. Because of its relative rarity there is no common surgical tactics for such patients. This type of burn trauma still remains under discussion. Aim of study Optimization of surgical treatment tactics in patients with severe chemical burns caused by household chemicals. Material and methods Medical histories of patients with life-threatening burns, caused by household chemicals. Results In order to remove the damaging agent, multiple incisions were performed as early as possible after admission. After stabilization, necrotized tissue was removed gradually to the superficial fascia. Single-stage autografting was considered unreasonable due to the lack of objective factors of the lesion depth. Hydrocolloid dressings were used for temporal closure of wounds. As tissues became clean we covered granulating wound by split-skin grafts. Conclusion Early fascial excision and delayed autoplasty is the priority method of surgical treatment of patients with life-threatening burns caused by household chemicals.

Лечение химических ожогов пищевода у детей

Objective . To study the treatment efficacy of chemical burns of the esophagus in children with different grades of lesion. Material and methods . For the last seven years in Dnipropetrovsk Regional Children’s Clinical Hospital there were 192 children on treatment with a diagnosis of chemical burn of the esophagus, out of them 108 (56.25%) boys and 84 (43.75%) girls, and prevailed children aged 1-3 years who made up 102 (53.1%). Among damaging agents caused esophageal burns were more often caustic ones 95 (49.47%). In most cases, there was grade II of lesion of esophageal burns in 71 (36.98%) children. Treatment of post-burn esophagitis includes detoxification, stomach lavage, pain management, antibiotic therapy, short course of corticosteroids. Estimation of the patient’s status provided during the first twenty-four hours. Further the restoration of esophageal patency was conducted with the use of instrumental methods of treatment. The main method of corrosive strictures of esophagus was gullet bougienage and dilation. Results . The patients of the study group were treated using bougie over guidewire dilators. Application of this methodology in treatment of patients with the esophageal burns allowed considerably reduce the amount of cicatrical esophageal stenosis, as well as such complications as perforations and mediastinitis. Conclusion . Proper provision of primary care and the selection of correct diagnostic and treatment tactics of patients with chemical burns of the esophagus helps to reduce complications and disability in children with this pathology.

COMPARATIVE ANALYSIS OF TREATMENT OUTCOMES IN PATIENTS WITH TYPES B AND C PYLON FRACTURES

Objective — to develop and implement improved approaches to the diagnosis and tactics of surgical treatment in patients with fractures of the distal tibia metaepiphysis.Material and methods. The study included 126 patients with fractures of distal tibia metaepiphysis of «B» and «C» types who underwent internal fixation with plates in 2005–2012. The authors analyzed surgical treatment outcomes within the period from 2.5 to 9 years (average of 5.7–2.3 years) of postoperative follow up. Average age of patients was 23.4±2.1 years. Patients were divided into the main group (64 patients) and the comparison group (62 patients). In the comparison group, traditional approaches to diagnosis and surgical treatment were used, including standard clinical examination and X-rays of the affected ankle in two views and the median access to the distal tibia metaepiphysis. In the main group, a specially elaborated algorithm for selection of optimal surgical tactics was utilized basing on the improved diagnostics program. Clinical and functional data were assessed by Foot and Ankle Outcome Score (FAOS) and SF-36 Health Survey. Roentgenological assessment was done by X-rays and CT scans. Statistical significance of the differences was evaluated by Wald-Wolfowitz and Fisher tests.Results. Improved approaches to the tactics of surgical treatment in patients with pylon fractures of «B» and «C» types allowed to reduce the incidence of unsatisfactory anatomical and functional outcomes from 43.5% to 28.1%. The number of satisfactory and good outcomes increased by 4.7% and 10.7% respectively after application of improved therapeutic and diagnostic approaches.Conclusion. Proposed improved approaches to verification of severe intraarticular fractures of the distal tibia metabiphysis allowed to increase the informative value of the diagnostic procedures and to avoid discrepancies between preand intraoperative assessment of fracture type by classifications of M. Mueller-AS (1989) and X. Tang, P. Tang (2012) as well as to avoid diagnostic errors in detecting the facet impression of the distal tibia metaepiphysis.

Color Doppler for retinopathy of prematurity

The data about use of color Doppler method to study the characteristics of eye blood flow in the preterm infants with retinopathy of prematurity (ROP) are presented in the review. The greatest attention is paid to arterial blood flow examination, and there are only single studies about venous blood flow in ROP. The results presented in different sources indicate on color Doppler informativity in the diagnostics of ROP, however, they are ambiguous and contradictory. It points to the necessity for the further studies on generalization and systematization of the eye blood flow characteristics in the disease, and also on recognition of the most useful indicators for assessing the severity of the pathological process, predicting its course and determining of the optimal management and treatment tactics for patients with ROP.

Comparative results of different methods of arterial reconstruction in the patients with critical stenosis of the femoral-popliteal-tibial segment

Introduction. Critical limb ischemia (CLI), which arises from atherosclerotic lesions of the arteries is quite often presently. This problem is actively discussed all over the world. In addition to the disability of the patients due to limb loss, the death rate from this disease is comparable to mortality from malignant tumors. Objective. Evaluate immediate and long-term results and optimize treatment tactics for patients with critical limb ischemia in multilevel lesions of lower limb arteries. Materials and methods. The examination and treatment of patients with CLI was carried out in the Research Institute of Surgery and Urgent Medicine of the First State Medical University of Saint-Petersburg named by I. P. Pavlov, as well as on the basis of the City Clinical Hospital «City Hospital No. 14» and St. Petersburg Research Institute of Emergency Care named by I. I. Dzhanelidze in the period from 2005 to 2016. The study is conducted in patients with atherosclerotic lesion of the main arteries of the lower extremities, which manifests itself as pain at rest and/or tissue loss (stage 3-4 of chronic arterial insufficiency of the limb according to Fontein-Pokrovsky classification). Results. Clinical success of all kinds of interventions was achieved in 166 (88.8 %) patients. However, the negative results were greater in the group where only angioplasty of the lower limb arteries was performed. Long-term results could be traced in 108 (57.8 %) patients for 6 months - 5 years. If we consider all groups as a whole, then the aggravation of ischemia occurred in endovascular intervention group in 62 % of patients, in the group of bypass operations - in 19.61 %, and in the group of hybrid interventions - in 17.65 %. Conclusion. Hybrid methods of treatment are the method of choice for patients with stage 4 ischemia of the lower limb with multilevel lesions of lower extremity arteries. Open surgery on the arteries of the lower extremities remains a very effective method of treating patients with critical ischemia. In turn, the use of endovascular methods is advisable in patients with severe concomitant pathology.

Diagnostic and treatment tactics in patients with pancreatic cystic lesion in the outcome of chronic pancreatitis

Aim: To substantiate the choice of the optimal treatment strategy for patients with pancreatic cysts on the background of chronic pancreatitis.
 Materials and methods: A retrospective-prospective analysis of the treatment of 58 patients (31 (53.4%) men and 27 (46.6%) women, aged from 26 to 73) with chronic pancreatitis complicated by the formation of cystic lesion was done.
 Results: Conservative treatment was applied in 8 (13.8%) cases, the puncturing technique was used in 19 (32,8%) cases, various surgeries performed in 31 (53.4%) patients. Conservative treatment was effective in 3 (37.5%) cases, puncture treatment – in 7 (36.8%), surgical – in 28 (90.3%) patients.
 Conclusion: Based on the findings, an algorithm of choosing the tactics of treatment of patients with pancreatic cysts in the outcome of chronic pancreatitis was developed in the clinic.

Mathematic Modelling of Stress in Healthy Knee Joint and After Arthroplastywith Different Typesof Endoprostheses

Purpose of study. To study stressed-deformed state of the healthy knee joint and after arthroplasty using endoprostheses with either preservation or substitution of the posterior cruciate ligament by the method of numerical mathematical modelling.Materials and methods.Peculiarities of stress distribution in bones were determined on three mathematical models - healthy knee joint and joint after arthroplasty using endoprostheses with either preservation or substitution of the posterior cruciate ligament at the set load (80 kg) in straightened leg and either 45° or 90° knee flexion.Results. In healthy knee joint with a straightened leg the stress in the tibia is 2.3 times higher than in the femur. With knee flexion the stress in bone tissue increases and this increase is more intensive in the femur. After arthroplasty using endoprosthesis with substitution of the posterior cruciate ligament the stress in the tibia and femur is higher at all flexion angles as compared to arthroplasty using endoprosthesis with posterior cruciate ligament preservationConclusion.The obtained data may be used for mathematical substantiation of the advantage of endoprosthesis with preservation of the posterior cruciate ligament and in complex with the data of national and international registers will enable to optimize the treatment tactics in patients to whom knee arthroplasty is indicated.

Mathematic Modelling of Stress in Healthy Knee Joint and After Arthroplastywith Different Typesof Endoprostheses

Purpose of study. To study stressed-deformed state of the healthy knee joint and after arthroplasty using endoprostheses with either preservation or substitution of the posterior cruciate ligament by the method of numerical mathematical modelling. Materials and methods. Peculiarities of stress distribution in bones were determined on three mathematical models - healthy knee joint and joint after arthroplasty using endoprostheses with either preservation or substitution of the posterior cruciate ligament at the set load (80 kg) in straightened leg and either 45° or 90° knee flexion. Results. In healthy knee joint with a straightened leg the stress in the tibia is 2.3 times higher than in the femur. With knee flexion the stress in bone tissue increases and this increase is more intensive in the femur. After arthroplasty using endoprosthesis with substitution of the posterior cruciate ligament the stress in the tibia and femur is higher at all flexion angles as compared to arthroplasty using endoprosthesis with posterior cruciate ligament preservation Conclusion. The obtained data may be used for mathematical substantiation of the advantage of endoprosthesis with preservation of the posterior cruciate ligament and in complex with the data of national and international registers will enable to optimize the treatment tactics in patients to whom knee arthroplasty is indicated.

FEATURES OF SURGICAL TACTICS FOR PATIENTS WITH COXO-VERTEBRAL SYNDROME

Purpose of the study – to design the algorithm of selection for rational surgical tactics for treatment of patients with coxo-vertebral syndrome.Material and methods. 175 patients with coxo-vertebral syndrome were included into the study who underwent total hip replacement in the period from 2009 till 2016. The authors analyzed outcomes of treatment of 134 patients at midterm follow up of 9 months (range from 8 to 10 months) after the surgery. Mean age of patients was 54,4±12,7 y.o. Patients were subdivided into a test group (94 patients) and control group (81 patients). Standard THR approaches were used in the control group by restoring anatomical center of rotation and lower leg length. The suggested algorithm of the optimal procedure selection was applied in the test group. Clinical and functional data was evaluated by Harris Hip Score and Oswestry score. Radiographic evaluation was performed based on x-rays of vertebral-pelvic complex in standing position, by functional x-rays, CT and MRI. Evaluation of differences significance between the groups was performed by MannWhitney U-test and McNemar test.Results. Application of proposed surgical approaches allowed to increase the number of patients with good clinical and functional outcomes (test group – 82,4%, control group – 26,7%) and achieve better function of hip joint and patients’ life quality in short-term postoperative period. Excellent outcomes by Harris hip score were observed in 53,2% of patients, in control group – in 9,7%. Share of the patients complaining of lumber pain, limping and need for a walking stick after THR in the test group was less than in control group. Share of patients demonstrating pain at palpation of spinous processes, with positive test of elevated extended leg and radicular syndrome was also significantly less in test group as compared to control group.Conclusion. Practical application of proposed algorithm for selection of a rational tactics of surgical treatment for patients with combined degenerative and distrophic pathology of the hip joint and spine allows in short-term after THR to statistically significantly improve treatment outcomes in comparison with patients that underwent conventional preoperative planning and THR.

Ovarian cancer: current approaches to classification, diagnostics, staging and differential management of patients

Purpose of this study: systematic analysis of the data available in the modern scientific medical literature on contemporary aspects of the diagnosis, staging and differential treatment tactics of patients with epithelial ovarian tumors.
 Research method used in this article is the systematic analysis of the medical literature, both domestic and western.
 Results. This article attempts to summarize the experience of modern medicine and the world’s leading centers for the fight against ovarian cancer of epithelial origin and offer solutions relevant to everyday clinical practice. Problems of the modern classification of forms of the disease are described in detail; description of instrumental diagnostic methods also is given in thus article; problem of lack of effective proved themselves in clinical practice of screening methods also was disccused; and, thus, current understanding of the disease staging and differential tactics for treatment of patients are given.
 Conclusion. One of the most important directions of development of gynecological oncology is a decision the existing problems related to the diagnosis and treatment of ovarian cancer: namely, the development of effective screening programs, improving diagnosis and therapy methods, the development of measures of postoperative management of patients with ovarian cancer, including medical rehabilitation measures.

Хирургическая тактика при лечении беременных с опухолевидными образованиями и опухолями яичников. Методология принятия решений

Хирургическая тактика при лечении беременных с опухолевидными образованиями и опухолями яичников. Методология принятия решений

FEATURES OF DIAGNOSTIC AND THERAPEUTIC TACTICS FOR BLUNT ABDOMINAL TRAUMA WITH DAMAGE TO THE PANCREAS

Abstract. Injuries of pancreas in the closed abdominal trauma remain the one of most challenging issues in diagnosis and choice of optimal therapy. Objectives. To analyze clinical results of the improved diagnostic and treatment tactics in patients with blunt abdominal trauma and damage to the pancreas. Material and methods. We report the results of treatment for 141 patients with pancreatic trauma treated from 1991 to 2015 at City Hospital No. 3 and City Hospital No. 40. All patients were divided into 2 groups. These groups were formed according to the time factor. The groups were comparable in age, gender, and pancreatic trauma severity. The study group consisted of 59 patients, treated in 2004-2015, and the comparison group consisted of 82 patients (1991–2003). The advanced diagnostic and treatment algorithm for the study group included modern instrumental diagnostic methods, such as ultrasound, computed tomography, diagnostic laparoscopy and improved surgical tactics to lower indications for omental plug, omentobursostomy, suturing capsule of pancreas and cholecystostomy. Results. This algorithm reduced the duration gap between hospitalization and surgery averagely from 10.7 to 4.0 hours, and the modified treatment tactics decreased the incidence of septic complications from 15.8% to 6.8%, and the mortality from 27.6% to 16.9%. Conclusion. As a rule, methods of radiodiagnosis detect only indirect signs of pancreatic injury in blunt abdominal trauma. It is advisable to perform omental plugging only as medical tactics of «damage control».

ANALYSIS OF MORTALITY FROM MUSCULOSKELETAL DISEASES AS UNDERLYING AND MULTIPLE CAUSES IN THE RESIDENTS OF THE TULA REGION

Musculoskeletal diseases (MSDs) are a topical medical, social, and economic problem. According to the 2015 data, MSDs in the structure of primary morbidity were 3.9% and those in the structure of mortality were 0.2% in the Russian Federation. Official mortality statistics is formed only by one (underlying) cause of death. The study of multiple causes of death will enable the understanding of its mechanisms, the necessity of making changes in the management tactics for patients and in the standards of medical care, as well as the possibility of correcting the mortality reduction plans. Objective: to investigate the reliability of statistics on MSD mortality and the ways of its reduction, by analyzing the underlying and multiple causes of death. Materials and methods. This investigation used a database on medical death certificates of the residents of the Tula Region in 2015. Mortality rates were calculated by conventional statistical methods. Death rates for the Russian Federation and the Tula Region were taken from the book «Medico-demographic indicators of the Russian Federation in 2015» by the Ministry of Health of Russia and C52 tables by the Federal State Statistics Service. The 2012–2014 European mortality databases were used for international comparisons. Results and discussion. The mortality rates were analyzed using the underlying and multiple causes of death. Expert evaluation showed that the 2015 mortality rates from MSDs were underestimated by approximately 11%. The MSD mortality rates in the Tula Region were 2.4 and 2.7 times higher than those in the entire Russian Federation and in Europe, respectively. Defects were found in drawing up medical death certificates. The reliability of mortality statistics was shown to be related to monitoring, physician training, and introduction of an automated system. Emphasis is laid on the correction of treatment tactics for patients with MSD.

Peculiarities of Reparative Osteogenesis of Injured Thoracic and Lumbar Vertebral Bodies at Different Terms after Trauma

The analysis of the results of morphologic examination of vertebral body bone tissue obtained intraoperatively from 43 patients (20 - 67 years) with thoracic and lumbar spine injuries at different terms after trauma was performed. All patients were operated on via anterior approach to create ventral fusion. In the examined serial samples of vertebral body structures the quality and regeneration potential of bone tissue were assessed. It was shown that cell differentiation during the osteogenesis process was closely associated with angiogenesis. In the zones with active growth of microcirculatory bed vessels the normal cycle of osteoblast and osteocytes took place while hypoxia and acidosis resulted in pathologic osteogenesis. In patients under 50 years, both males and females) the full value consolidation time averaged 5 months. In patients over 50 years, independently of the gender, the decrease of spongy structures volume and bone mineral density was observed. The recommendations on surgical treatment tactics of patients with thoracic and lumbar vertebral body injuries were given.

Peculiarities of Reparative Osteogenesis of Injured Thoracic and Lumbar Vertebral Bodies at Different Terms after Trauma

The analysis of the results of morphologic examination of vertebral body bone tissue obtained intraoperatively from 43 patients (20 - 67 years) with thoracic and lumbar spine injuries at different terms after trauma was performed. All patients were operated on via anterior approach to create ventral fusion. In the examined serial samples of vertebral body structures the quality and regeneration potential of bone tissue were assessed. It was shown that cell differentiation during the osteogenesis process was closely associated with angiogenesis. In the zones with active growth of microcirculatory bed vessels the normal cycle of osteoblast and osteocytes took place while hypoxia and acidosis resulted in pathologic osteogenesis. In patients under 50 years, both males and females) the full value consolidation time averaged 5 months. In patients over 50 years, independently of the gender, the decrease of spongy structures volume and bone mineral density was observed. The recommendations on surgical treatment tactics of patients with thoracic and lumbar vertebral body injuries were given.

Cone-beam computerized tomography use for determination of optimal treatment tactics in patients with tear drainage system pathology conditions

At present time, many methods to diagnose pathological conditions of the lacrimal drainage system are known. An improvement of radiological methods is necessary for the choice of optimal treatment tactics in patients of this category. Authors propose their radiological method for tear drainage impairment diagnosis - a cone-beam computerized tomography (CBCT) of paranasal sinuses with simultaneous contrast examination of lacrimal pathways. Data analysis algorithm is worked out. Results of lacrimal pathways status estimation based on CBCT with contrast test in 53 patients allowed determining the lacrimal pathways stenosis levels, structural aspects of the lacrimal sac walls, nasolacrimal channel, as well as the impact of anatomical structural features of the nasal cavity and paranasal sinuses on the development of the individual pathological condition of the lacrimal pathways. This determined the following optimal treatment tactics. Conclusion: this method is highly informative, cost-effective with low radiation exposure and possibility to perform serial follow-up examinations in patients with lacrimal pathways pathological conditions. Therefore, this could help a clinician in correct diagnosis and in determination of optimal treatment tactics.

The efficacy of psychopharmacotherapy of late onset depression: the optimization of treatment duration

To analyze possibilities of using different methods to increase the efficacy of psychopharmacotherapy of late onset depression, in particular to increase treatment duration. The study included 378patients, aged from 50 to 82 years (mean age 60.6±8.4). Patients were stratified into groups with short (4--8 weeks), moderate (12 weeks) and long (20-34 weeks) duration of psychopharmacotherapy. Treatment effect was much lower after <8 weeks of treatment compared with that after 12 weeks (the comparison of these groups was not available because the initial samples were not). To the 24th week, 63.9% of the patients responded to treatment, 43.4% achieved remission. Partial response and stable positive dynamics to the 12th week (about ½ of the patients achieved remission) were predictors of response with treatment duration <24 weeks. Based on the results obtained, the authors developed algorithms for choosing treatment tactics in patients with late onset depression in dependence of the results of the first 12 weeks of psychopharmacotherapy.

Treatment tactics for patients with combined atherosclerotic lesions of brachiocephalic and coronary arteries

To evaluate the tactics of surgical treatment of patients with coronary heart disease and atherosclerotic lesions of cerebral vessels in dependence of risk stratification of heart and brain complications. One hundred and fifty-six patients were examined. Cerebral and coronary blood flow and functional state of the brain and heart were studied. According to treatment characteristics, 3 groups were singled out: patients of the 1(st) group underwent simultaneous surgery of coronary and brachiocephalic arteries, patients of the 2(nd) group were first operated for brachiocephalic arteries, in the 3(rd) group, bypass graft was performed in the first stage. A role of coronary and brachiocephalic arteries, functional state of the myocardium and brain in the postoperative risk was established. The authors suggest the algorithm for choosing the order of priority of surgical interventions on coronary and brachiocephalic arteries.

Современные возможности лечения дифференцированного рака щитовидной железы, резистентного к терапии радиоактивным йодом: резолюция по итогам Экспертного cовета

The meeting of experts, concerning the treatment of thyroid cancer was held in Moscow in June 2016. The aim of the meeting was unsolved tasks in the field of therapy of the patients with radioactive iodine-refractory differentiated thyroid cancer. Nowadays, this group of patients still has a poor prognosis with respect to life expectancy. The experts are faced with some difficulties in choosing the treatment tactics in patients after radioiodine therapy have become ineffective and we observe disease progression. And still valid questions remain unsolved: when should doctors stop therapy using radioactive iodine? When should patient start therapy using targeted agents? What kind of targeted agent should specialist choose for treatment of this desiase? How should one manage the developing side effects against the backdrop of targeted therapy? These and some other problems have been discussed within the framework of this counsel.

Complex evaluation of clinical and instrumental data for grounding of the tactics of operative treatment in patients with resistant epilepsy forms

Frequent epileptic seizures and side effects of drugs have a significant negative impact on the quality of life. The main goal in the treatment of such patients is not only to decrease the number of attacks and their severity, but also to improve social adaptation. Surgical treatment for some forms of pharmacoresistant epilepsy improves prognosis and enhances the quality of life of patients, and the result depends on the duration of the disease. The main task of the preoperative examination is the most accurate localization of the epileptogenic zone. In the case of proximity or the overlapping of the epileptogenic zone with functionally significant parts of the crust, additional surveys to determine the latter are conducted. The survey may be conducted using non-invasive techniques, such as MRI, functional MRI, positron emission tomography (PET), single photon emission computed tomography (SPECT) and extracranial electrical stimulation or invasive direct electrical stimulation of the cortex.