Experimental substantiation and clinical use of a combination of dermal matrix with allogenic or autologous cells for the treatment of extensive traumatic wounds.

We carried out a comparative experimental and clinical study of the efficiency of the combination of dermal matrix with autologous and allogenic cells for creation of an optimal biological wound coating. Experiments on outbred mice have demonstrated that the use of dermal matrix in combination with allogeneic or autologous cells shortens the inflammation phase and accelerated maturation of the granulation tissue. Clinical application of biological wound dressing based on dermal matrix in combination with autologous or allogeneic mesenchymal multipotent stromal cells prevented septic complications and shortened the time of preparing extensive traumatic wounds with skin defect to autodermoplasty.

[Coagulation profiles during cardiac surgery].

OBJECTIVE: To evaluate patients' hemostasis after cardiac surgery using thromboelastometric and impedance aggregometry. MATERIALS AND METHODS: 66 patients were examined intraoperatively. Comparison group included 45 blood donors. Hemostasis was tested for thromboelastometricRotem Gamma with the assessment of external (exTem) and internal (inTem) pathways of coagulation tests performed detection of heparin (hepTem) and cytochalasin-D-inactivation of platelets (fibTem) to assess the level of fibrinogen. Collagen-induced platelet aggregation was determined in an aggregometer CHRONO-LOG (USA). RESULTS: Significant deviations of the parameters of hemostasis were detected in 52 of the 66 studied patients. In group-1 (23 patients) revealed a residual effect of heparin. The effect manifested prolongation CT (clotting time) inTem to an average of 241 +/- 15 s, compared with CT hepTem--181 +/- 7. Patients in this group were in need of additional administration of protamine sulfate. Postoperative bleeding and resternotomia were observed in 3 patients of group-1. In group-2 (25 patients) CT inTem was 216 +/- 21 with significantly fewer CT hepTem (272 +/- 26). The data indicated excess of protamine sulfate. Platelets aggregation decreased compared to the norm. According to the obtained results, the addition of protamine sulfate is not required, however, in 7 cases the protamine sulfate was administered in a dose of 8.9 +/- 0.8 mg in 6 cases resternotomiya required. In the third group (n = 6) bleeding was observed in 4 patients. The difference in CT-hepCT was significant. Significant variations were revealed in the tests of the activity of the extrinsic pathway of coagulation and cytochalasin-D-induced inactivation of platelets: exMCF- 42 +/- 2 mm (normal 57 +/- 15 mm), fibMCF 5.0 +/- 0.3 mm (norm 12.8 +/- 4.3 mm). The concentration of platelets and their aggregation activity was sharply reduced. Disorders of hemostasis in the third group, designated as dilution coagulopathy. CONCLUSION: Turning thromboelastometric and impedance aggregometry in the study of the coagulation profile of patients undergoing cardiac surgery in postperfusion period brings valuable information and allows a differentiated treatment of hemostasis disorders.

[Homeostasis changes during rehabilitation period after acute chemical poisoning].

The article deals with review of 78 patients of rehabilitation toxicological unit. The patients received resuscitation and detoxification. All patients were divided into three groups; 1st group--patients after poisoning with psychopharmaceuticals, 2nd group--patients after poisoning with cauterizing liquids and 3rd group--patients with encephalopathy after poisoning with neurotoxin (psychopharmaceuticals, narcotics and ethanol). Disorders of rheology, haemostasis and endotoxicosis accrued in all groups. These disorders were a signs of the erythrocytes and platelets aggregation developing and viscoelasticity disorder. Homeostasis changes during rehabilitation period need an accurate diagnostics for purposeful treatment of the defined disorders.

[The morphologic evaluation of adhesive activity].

The morphologic evaluation of adhesive activity of human thrombocytes using both vital dye of cells and registration of adhesion process with fluorescent microscope is proposed. The regression dependence between adhesive activity of human thrombocytes and morpho-functional and aggregative activity of thrombocytes is established. The blood samples of 100 blood donors, 100 patients with hematologic pathology, 110 patients of traumatology, 50 patients with acute exogenous intoxications and 20 patients with chronic trophic ulcers were analyzed. The drastic decrease of adhesive activity of human thrombocytes and number of adhesively active thrombocytes was established in circulating blood of patients with bleedings of various etiology and hematologic patients. The significant increase of adhesive activity of human thrombocytes and number of adhesively active thrombocytes in patients with thrombosis is established. The morphologic evaluation of quality of thrombocytes is effective in case of analysis of biologic value of all population of circulating cells.

Effect of concentration of platelet-derived growth factor on proliferative activity of human fibroblasts.

Serum concentration of platelet-derived growth factor was measured in patients with trophic ulcers and proliferative activity of human fibroblasts was measured in wells with different content of added serum platelet-derived growth factor. In parallel, morphofunctional analysis of platelets from the whole blood of these patients was performed. A close correlation was found between morphofunctional parameters of blood platelets and serum concentration of platelet-derived growth factor. Platelet-derived growth factor in concentrations below 150 pg per well stimulated fibroblast proliferation and preserved their viability. Platelet-derived growth factor in concentrations >200 pg per well suppressed fibroblast proliferation and impaired their viability.

[Mechanic reinfusion in emergency surgery].

The article highlights techniques and effects of intraoperative mechanic blood reinfusion in patients with trauma and intraabdominal bleeding in extend, exceeding the self circulating blood volume. The high efficacy of the self blood reinfusion during the emergency operation allowed the 2-fold decrease of the hospital and overall mortality. The mechanic blood reinfusion proved to be a safe and clinically effective method of the globular blood volume deficiency compensation, especially in emergency surgery.

[The intraoperative auto- and allohemotransfusion by massive bleeding in emergency abdominal surgery].

The results of intraoperative hemotransfusion of 112 patients with abdominal injuries, complicated with bleeding and the loss of more then 70% of the circulating blood. The aim of the study was to compare the efficacy of auto- and allohemotransfusion. The first method allowed to decrease both the overall lethality (p=0.039) and postoperative lethality (p=0.018). The odds ratio by the predominate autohemotransfusion was 1.385 (95% 1.101-1.741), where as the odds ratio by the predominate allohemotransfusion was 0.403 (95% 0.183-0.885; p=0.011).

Morphofunctional evaluation of the effect of collagen-1-based dressing on skin regeneration after burn trauma in mice of two genetic strains.

Morphofunctional evaluation of the effect of biological dressing with collagen-1 on healing of 3A degree burn wound in outbred and mutant Hr(hr)/Hr(hr)(hairless) mice was carried out by the histological method and optic radioautography. A pronounced stimulatory effect of the dressing on skin regeneration in mice was demonstrated. According to radioautography data, early dressing of the burn wounds in Hr(hr)/Hr(hr)mice led to active proliferation of epithelial cells in dermal cyst and vascular endotheliocytes. The possible mechanisms of the stimulatory effect of collagen-based dressing on wound healing are discussed.

[Selective adsorption of endotoxin in the complex treatment of patients with severe sepsis].

Severe sepsis and septic shock remain the most serious problem of critical care medicine today with a mortality of 25-80%. Bacterial endotoxin is of considerable importance in the pathogenesis of sepsis. A selective hemosorbent in which endotoxin adsorption is accomplished via its binding to a synthetic peptide (LPS-A) has been recently designed in Sweden. The purpose of the study was to evaluate the efficiency of using the LPS-A in the complex treatment of patients with severe sepsis. Eight patients in whom the course of the underlying disease was complicated by the development of gram-negative sepsis in the postoperative period were examined. The patients had an APACHE II score of 20.4 +/- 4.5 LPS-A was performed using the hemosorbent Alteco LPS (Lund, Sweden) and an Aquarius hemoprocessor (Edwards Lifesciences) (U.S.A.). The use of LPS-A caused a significant reduction in endotoxin levels by 2.9 times. The level of procalcitonin was increased in all patients; after a LPS-A session, it was significantly decreased by 1.9 times. The use of LPS-A resulted in diminished tachycardia, elevated blood pressure and could reduce the doses of vasopressor amines. There was an improvement in lung gas exchange parameters. A study of the effect of LPS-A on the immune system showed a significant reduction (36.6%) in neutrophil oxygen-dependent metabolism according to the data of the spontaneous HCT test, a 2.4-fold decrease in large circulating immune complexes, and a rise in the count of mononuclear cells that died both by necrosis and apoptosis, the count of the cells significantly increased by 5.3 times in late apoptosis. A LPS-A session caused a significant drop in the blood level of endotoxin and procalcitonin and it was accompanied by a trend toward better hemodynamics and lung gas exchange and alleviated organ dysfunction. At the same time LPS-A showed the ambiguous effect on immune system parameters, which calls for further study.

[Apoptosis of mononuclear cells and dead leukocytes in venous blood of septic patients].

Apoptosis of mononuclear cells, dead leukocyte and CD95+ lymphocytes content in venous blood of 15 patients were evaluated by flow cytometry within 2-3 day after diagnosis of sepsis. The number of CD95+ lymphocytes increased in 40% of the cases and that of lymphocytes expressing Fas receptor decreased in 27%. The number of mononuclear cells in venous blood increased 7 times compared with physiological norm; this rise was a reliable predictor of the unfavourable outcome of the disease. Elimination of dead leukocytes by granulocytophoresis produced good therapeutic result.

[Immunomodulatory effect of extracorporeal hemocorrection in patients with surgical sepsis].

The study was undertaken to evaluate the immunomodulatory effects of various methods of extracorporeal hemocorrection in septic patients. Thirty-two patients in whom the course of the underlying disease was complicated by the development of sepsis were examined. A package of therapeutic measures involved debridement of an infection focus, de-escalation antibacterial therapy, nutritional support, and immunomodulatory therapy. All the patients underwent procedures of plasma filtration and continuous venovenous hemofiltration; granulocytopheresis was carried out in 5 patients. Granulocytopheresis was shown to eliminate dead leukocytes from the bloodstream within a few hours, which contributed to clinical improvement. Plasmafiltration in patients with sepsis resulted to a reduction in the degree of a systemic inflammatory reaction, to normalization of coagulation homeostasis, which indirectly affected immunological parameters. Continuous venovenous hemofiltration made it possible to make continuous elimination of the low and average molecular-weight substances, corrected liquid balance, and well affected gas exchange in the lung.

[Evaluation of severity of immune disorders and prognosis of the development of pyo-septic complications in patients with emergency surgery pathology].

Any lesion in organism, causing the development of inflammation, is followed by changed work of the immune system that is extremely important for prognosis of the course of the pathological process. The adequate compensation-defense reaction was estimated using well-known immunological tests and normal reaction of the immune system was determined to be different from the pathological reaction, especially in patients in critical state. The adequate reaction of the immune system is characterized by mild leukocytosis, two-three fold increase of the spontaneous HCT test, normal or moderately pronounced indices of the cellular and humoral links of immunity. The markers of the formation of secondary immune incompetence are not only decreased but also extremely increased indices of immunogram at early terms of the disease.

[Compensation for circulating blood volume in fatal blood loss].

Despite the extended potentials of modern medicine, noncompensated blood loss remains one of the leading causes of death in the able-bodied population all over the world. At present, there is no uniform policy of transfusion maintenance and intensive care in victims with severe decompensated blood loss. The purpose of the study was to assess the results of compensation for acute blood loss in victims with concomitant injury and wounds at various sites, which were attended by the loss of a circulating blood volume (CBV) with the use of new technologies. The authors retrospectively assessed the specific features of the course of anesthesia and compensation for blood loss in 66 male victims (mean age 37 +/- 1.5 years) with concomitant injury and various wounds complicated by acute CBV loss. CBV was compensated for by the currently available infusion media; globular blood volume deficit was restored via intraoperative instrumental reinfusion of autoblood and donor blood. The proposed procedure for infusion-transfusion therapy made it possible to stabilize the patient's condition and to perform emergency surgical treatment in victims with fatal blood loss. Total mortality in the chosen intensive care modality was 62.1%.

[Treatment of IIIa grade burns with the biologic band].

The biologic band is created on the base of type I collagen and platelet derived growth factor. It was applied for extensive burns of IIIa grade at 1-2nd day after a trauma, which led to epidermis reconstruction at 5-7th day. Authors assume that the effect of the band is determined by the time of its use--1-2nd day, when stimulating exudation qualities combine with healing properties of the bandage. The effectiveness of the collagen band showed to be equal to those of fibroblast transplantation.

[Immunological aspects of the early application of extracorporeal hemocorrection techniques in the complex therapy of purulent mediastinitis].

Acute purulent mediastinitis (APM) is one of the most complicated forms of surgical infection, showing a high incidence of sepsis--from 45 to 100%, mortality rates of 17 to 80%. Sixty-eight patients with APM admitted to the N. V. Sklifosovsky Research Institute of Emergency Care in October 2002 to March 2007 were examined. Postoperatively, all the patients received extracorporeal hemocorrection techniques (EHT): plasmapheresis (PA) via filtration and continuous venovenous hemofiltration (CVVHF). According to the time of initiation of EHT, the patients were divided into 2 groups: 1) 34 patients in whom EHT was initiated within the first 24 hours after surgery; 2) 34 patients in whom it was started on postoperative day 2. The efficiency of early use of EHT in the complex therapy of APM was evaluated. The early initiation of EHT (PA and CVVHF) caused a reduction in endogenous intoxication and the magnitude of a systemic inflammatory reaction, which resulted in the rapidest restoration of the size of major populations and subpopulations of lymphocytes and prevented the development of immune system incompetence. The early use of EHT caused a significant reduction in hospital mortality (11.8 and 35.3% in the early and late EHT use groups, respectively).

Stimulation of regeneration of hyaline cartilage in experimental osteochondral injury.

A model of osteochondral intra-articular defect in rats is presented. During spontaneous healing, the stage of formation of granulation tissue is followed by its replacement with bone and fibrous tissue. Chondroinductive properties of collagen 1 sponge used for defect filling manifested in the formation of fibrous cartilage with fields of hyaline cartilage. Filling of the defect with collagen 1 sponge containing bone powder stimulated regeneration of the bone tissue and hyaline cartilage.

The use of bioactive wound dressing, stimulating epithelial regeneration of IIIa-degree burn wounds.

Clinical and morphological comparison of wound healing after transplantation of living cultured allofibroblast on days 1-2 after the injury, collagen-1-based dressing with PDGF-BB, and traditional dressing with levomecol ointment showed that bioactive dressing accelerated wound epithelialization (5-7 days vs. 20-22 days with gauze dressing); the incidence of suppurative complications decreased, no crust formed, and epithelialization was not associated with the formation of a hypertrophic cicatrix. Biological dressing based on living cultured allofibroblasts and collagen-1 with PDGF-BB exhibited equal stimulatory effects on burn wound healing.

[The level of dead blood leukocytes in sepsis and the significance of their elimination by extracorporeal hemocorrection techniques].

Sepsis with 18-to-33% mortality also remains the most serious problem of modem medicine today. Forty-five patients treated at the N. V. Sklifosovsky Research Institute of Emergency Care in June 2006 to February 2008 were examined. Twenty-seven primary blood donors were examined to determine the physiological concentration of dead leukocytes. Two groups of patients were formed according to the signs of a systemic inflammatory reaction (SIR). A study group included 29 patients in whom the course of the underlying disease was complicated by the development of sepsis. All the patients from the study group underwent extracorporeal hemocorrection techniques (EHT): plasma filtration (PF) and continuous venovenous hemofiltration (CVVHF). A granulocytopheresis procedure was performed in 4 patients. A control group comprised 16 patients without clinical signs of SIR. The blood taken from patients with sepsis showed the significant increase in the levels of dead leukocytes as compared with both the physiological normal values and the values obtained in patients without signs of systemic inflammation, which significantly correlates with the severity of organ dysfunction. The elevated content of dead leukocytes is an independent risk factor for a poor outcome. Plasma filtration used in sepsis patients facilitates a significant reduction in the blood concentration of dead leukocytes. The first experience with granulocytopheresis in patients with severe sepsis, a leukemoid reaction and high absolute concentrations of dead leukocytes is indicative of its clinical effectiveness, which is manifested itself by the elimination of dead leukocytes.

[Clinical assessment of immune parameters at surgical patients with syndrome of systemic inflammatory reaction].

Results of immunological examination of 423 patients with syndrome of systemic inflammatory reaction of different ethiology (mediastinitis--78 patients, peritonitis--85, severe acute pancreatitis--91, trauma of thorax and abdomen complicated with massive hemorrhage--111, severe burn trauma--40 patients) are analyzed. For complex and objective assessment of immune reaction the system of scores has been developed. This scale permitted to detect the immune disorders, to diagnose the degree of immune insufficiency at early stages of disease, to predict the purulent complications and to start timely immune therapy.

[Assessment of bactericidal and growth-inhibiting activity of blood serum using flow cytometry and photometry].

Method of measurement of biological fluids bactericidal activity against Staphylococcus aureus using laser flow cytometry has been developed and proposed for clinical use. Overall bactericidal activity of sera of healthy donors has been assessed by this method. Strong positive correlation between bactericidal activity measured by flow cytometry and ability of the sera of healthy donors to inhibit bacterial growth assessed by photometric method was determined. High degree of positive correlation between results of cytometry and classical microbiological method of measurement of mentioned parameters has been shown.