[Medical tactics, approaches and complex treatment effectiveness in case of multiple trauma caused by a fall from a height]. / Vrachebnaya taktika, podkhody i effektivnost' kompleksnogo lecheniya postradavshego s politravmoi, poluchennoi pri padenii s vysoty.

OBJECTIVE: To demonstrate the approaches' implementation of specialized multidisciplinary and high-tech medical care in multistage complex treatment of patient with multiple trauma including combined severe trauma of the maxillofacial region such as minimally invasive surgical tactics with early and delayed osteosynthesis (e.g. selection of optimal surgical tactics within the periodization of traumatic disease concept). Moreover, the implementation of rational advanced intensive pathogenesis drug therapy with the prevention of infectious complications in cast of severe injuries. MATERIAL AND METHODS: The tactics, approaches and results of multistage complex specialized treatment of patient K., 56 years old who has got severe concomitant injuries to various areas of the body and extremities (including multiple maxillofacial trauma) after falling from a height are presented. CONCLUSION: Rational surgical tactics and the timely initiation (immediately after admission of the victim to 1st level trauma center) of pathogenesis intensive therapy with modern drugs and antibiotics contributed to the exclusion of infectious complications in the third period (the period of maximum likelihood of complications) of traumatic illness. Comprehensive treatment of a victim with multiple trauma based on the principles of specialized, multidisciplinary and high-tech medical care is able to provide a favorable clinical outcome - the recovery with the restoration of the damaged anatomical structures functionality and the absence of cosmetic defects.

[Comprehensive treatment of a victim with gunshot injury of the head complicated by infection]. / Kompleksnoe lechenie postradavshego s infektsionno oslozhnennym ognestrel'nym povrezhdeniem golovy. Vybor effektivnoi taktiki lecheniya.

Gunshot head injuries make up 35% of all injuries. Brain injuries are diagnosed in 42.2% of cases, maxillofacial region - 35.7%, eye - 13.9%, outer and inner ear - 3.2%. These damages account 14.8%, 12.5%, 4.9% and 2.9% of the total number of injuries, respectively. In our opinion, primary surgical treatment of gunshot wounds should be carried out in a strict system of multiple-stage surgical management in accordance with the principles of treating wounds from high-speed weapons.

[Clinical experience with various techniques integrated treat the wounded with gunshot fractures of limbs]. / Klinicheskii opyt primeneniya razlichnykh metodik kompleksnogo lecheniya ranenykh s ognestrel'nymi perelomami kostei konechnostei.

AIM: To increase an efficiency of complex treatment of patients with diaphyseal gunshot fractures of long bones by introduction of modern minimally invasive surgical techniques of internal osteosynthesis into clinical practice of civil health care and to improve the outcomes in victims. MATERIAL AND METHODS: Prospective comparative clinical trial included 104 victims from the Republic of Yemen with gunshot wounds of limbs of various severity for the period 2009-2011. There were diaphyseal fractures of long bones of limbs associated with soft tissue injuries. Men were predominant (80.7%). Age ranged from 15 to 80 years (mean 38,5 ± 5,7 years). Various surgical techniques of simultaneous and staged treatment were used for gunshot fractures of long bones of limbs. Additional immune therapy was prescribed to prevent infectious complications in the most severe cases. RESULTS AND DISCUSSION: Victims were comprehensively treated according to different staged treatment: conventional surgical treatment with external fixation devices or early primary minimally invasive functionally stable osteosynthesis with LCP/BIOS plates were applied for low-energy fractures; in case of high-energy fractures the first stage included external fixation devices deployment followed by their subsequent replacement during delayed minimally invasive osteosynthesis. The essence of improvement is pursuit to simultaneous minimally invasive surgery by using of current plates for osteosynthesis and preventive immunotherapy of immune dysfunction to eliminate infectious complications. As a result, we obtained 2-fold decrease of surgical invasiveness (r≤0,01) and hospital-stay (r≤0,01). Repeated osteosynthesis was not made. Also 4-fold and 40-fold reduction of infectious and noninfectious complications was observed. This management was accompanied by reduced rehabilitation tine and significantly improved quality of life. CONCLUSION: Improved technique and algorithm of complex treatment of diaphyseal gunshot fractures of long bones of limbs were described. Early minimally invasive functionally stable osteosynthesis with modern implants and non-specific immune prevention of infectious complications are more effective and economically justified compared with conventional treatment including external fixation devices without immunoactive therapy.

[Kinetics of Virus Load HCV-RNA in Blood Serum and Peripheral Mononuclear Cells in a Patient with Hepatocirrhosis and Chronic Virus Hepatitis C Termination Treated According to Noninterferon Treatment Scheme (Cycloferon + Ribavirin)].

A clinical case of hepatocirrhosis with chronic hepatitis C termination (1b genotype) is described. Taking into account the cirrhotic stage of the disease, the extrahepatic HCV replication in the peripheral mononuclears, unfavourable HCV genotype, infavourable IL-28B gene polymorphism, inefficiency of the previous two courses of the standard antiviral therapy (PegIFN + ribavirin) and secondary immune deficiency, noninterferon antiviral therapy for 24 weeks was used in the treatment of the patient: interferon-inductive therapy with cycloferon in combination with ribavirin. There was observed by the 12th week of the treatment biochemical remission and a significant decrease of the virus load from 1 x 10(7) IU/ml to 7 x 10(5) IU/ml in the blood serum and from 1.35 x 10(7) IU/ml to 8 x 10(5) IU/m in the peripheral mononuclears. Investigation of the molecular biological markers of the viremia (PCR HCV-RNA) in the cells of peripheral mononuclears is an obligatory diagnostic technology in cases with suspected extrahepatic HCV infection. The kinetics of the virus load and the positive dynamics of the immunological indices in the patient at the cirrhotic stage of chronic virus hepatitis C are indicative of the efficient etiopathogenic approach with the use of the noninterferon treatment scheme (cycloferon + ribavirin), when recombinant interferons are contraindicated.

[Monitoring of influenza and other respiratory diseases causative agents in children, hospitalized with community-acquired pneumonia in 2012-2013 epidemic season].

AIM: Study the circulation of respiratory viruses in children with community-acquired pneumonia (CAP) during the period from October 2012 to May 2013. MATERIALS AND METHODS: 136 children with CAP aged from 3 months to 16 years with ARI symptoms at the disease debut were studied. RNA/DNA of influenza A, B, parainfluenza (PI); adeno-, rhino-, RS-viruses, corona-, metapneumo- (MPV) and bocaviruses were detected in nasopharynx smears by PCR with hybridization-fluorescent detection in real time. Antibodies against influenza viruses A/H1N1/pdm09 California/07/09, epidemic reference strains of influenza viruses A/H1N1/Brisbane/59/07, A/ H3N2/Victoria/361/201 1, B/Wisconsin/1/10, against PI viruses type 1, 2, 3 were determined in paired sera by HAI. RESULTS: In February-March 2013 the number of children protected by antibodies against influenza decreased, and circulation of influenza viruses A/H3N2 and A/H1N1/ pdm09 was detected. Rhinoviruses and PI viruses were determined throughout the epidemic season, bocavirus and adenoviruses--during the autumn-winter period, RS-virus and MPV--during winter-spring. Coronaviruses were not detected. The peak of virus detection was established in February when the threshold of influenza and ARI morbidity was exceeded. The main pathogens of children of the first 3 years of life are rhinoviruses, RS-virus, PI viruses and bocavirus. RS-virus infection at the debut of CAP in children younger than 3 years in 55.5% of cases is associated with the development of broncho-obstructive syndrome. Bocavirus infection in 50% of cases progresses with laryngo-tracheitis and bronchiolitis. CONCLUSION: The fraction of viruses in etiologic structure ofARI in children varies depending on immune layer, season and age of children. Etiology of viral infection at the debut of CAP could only be proven using specialized laboratory studies.

[Performance evaluation of comprehensive treatment of patients with infectious complications of bullet-extremity fractures].

The objective of the study was to examine the effectiveness of complex treatment of patients with infectious complications of gunshot fractures of limb bones using advanced minimally invasive surgical technologies phased osteosynthesis and new approaches of drug therapy. A prospective, comparative study of the results of examination and treatment of 60 patients with infectious complications of gunshot diaphyseal fractures of the long bones of the limbs treated in hospital Almutavakel (Sana'a, Republic of Yemen) in the period 2009-2011. Patients were randomized and divided into groups depending on the treatment regimen: a comparison (30 patients) received traditional scheme in which only apply external fixation devices or metal obsolete models and basic (30 patients), received treatment for advanced techniques include minimally invasive surgical sanitation of infected fracture zone followed by differentiated (depending on the size of the existing bone defect) tactics of consistent and gradual minimally invasive functionally stable osteosynthesis with modern APS and implants on a background of conservative therapy consisting of Cycloferon. The study showed a high clinical and cost-effectiveness of improved methods compared to traditional, that allows to recommend it for the provision of specialized medical care in the treatment of patients with infectious and complicated gunshot fractures of the long bones of the limbs.

[Efficacy of the infusion hepatotropic drug remaxol in the pathogenetic therapy for cirrhotic stage chronic viral hepatitides]. / Effektivnost' infuzionnogo gepatotropnogo preparata remaksol v patogeneticheskoi terapii khronicheskikh virusnykh gepatitov na tsirroticheskoi stadii.

AIM: To investigate the impact of therapy with the infusion hepatoprotector remaxol on liver function in cirrhosis in the outcome of chronic viral hepatitides (CVH): HCV, HBV, HCV+HBV, and HBV+HDV. SUBJECTS AND METHODS: Sixty-five patients aged 26 to 76 years, who had been diagnosed as having liver cirrhosis (LC) in the outcome of CVH: HCV, HBV, HCV+HBV, and HBV+HDV were examined. During infusion therapy, every day 32 cirrhotic patients in the outcome of CVH B or C received intravenous remaxol 400 ml in a jetwise manner once daily for 11 days. A comparison group comprised 33 patients with the similar condition who had intravenous ademetionine 400 mg in a jetwise fashion during infusion therapy with crystalloids (400 ml of isotonic sodium chloride solution, Ringer's solution) for 11 days. RESULTS: After an infusion therapy cycle, the study group patients were recorded to have more significantly reduced cytolytic and cholestatic parameters. The pronounced hepatotropic effect of the drug was confirmed by the rate of a decline in the average concentrations of alanine aminotransferase, aspartate aminotransferase, and total bilirubin. In the study group patients, the relative values of a decrease in the levels of these biochemical parameters were 29, 29, and 40% versus 15, 20, and 9% in the control patients. CONCLUSION: Infusion therapy with remaxol in the combination treatment of the patients with viral LC not only improves liver function (reduces the degree of cytolysis, cholestasis), but also exerts a cytoprotective effect on peripheral blood cells (leukocytes, lymphocytes, platelets).

[Colonization properties of opportunistic bacteria isolated from children with pneumonia].

AIM: Evaluation of phenotypes and pathogenicity factors of 476 opportunistic bacteria isolated from respiratory samples of 973 children with community-acquired pneumonia and 36 children without respiratory infection symptoms. MATERIALS AND METHODS: Quantitative method of tracheal aspirate and nasopharyngeal swab seeding into certified nutrient media was used, identification was carried out according to standard techniques. RESULTS: Adhesive, "anti-interferon", anti-lysozyme and inherent bactericidal activity of Escherichia coli and Klebsiella pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa and Acinetobacter spp. were established to ensure in combination with known aggression factors their colonization advantage compared with other pneumopathogens. Adhesion indexes of Gram-negative bacteria lower than 2.5 are shown as markers of invasive strains. Anti-lysozyme activity level lower than 2.14 microg/ml and lack of "anti-interferon" activity characterize non-invasive opportunistic bacteria strains. CONCLUSION: The detected phenotypic features of opportunistic bacteria may be used in clinical practice for evaluatio of etiologic importance of microorganisms isolated from tracheal aspirate in pneumonia patients.

[Pulmonary vasculitis as a clinical mask of HCV infection: efficiency of interferon-free antiviral therapy].

The paper describes a clinical case of pulmonary vasculitis caused by hepatitis C virus (HCV). Its diagnosis was established on the basis of in-depth laboratory testing and an investigation of the molecular biological markers of viremia (polymerase chain reaction--PCR--HCV RNA) in peripheral blood mononuclear cells. By taking into account of extrahepatic HCV replication and contraindications to interferon therapy, the female patient was given an interferon-free antiviral therapy cycle using an interferonogenic inductor in combination with ribavirin. Pathogenic therapy (methylpred and ursodeoxycholic acid) was additionally performed. An interferon-free regimen of cycloferon + ribavirin led to sustained remission of HCV infection running with its systemic manifestations. The therapy could improve the function of not only the liver, but also the lung. In suspected extrahepatic HCV infections, an investigation of molecular biological markers for viremia (HCV RNA PCR) in the peripheral blood mononuclear cells is an essential diagnostic technique. Interferonogenic inductors, cycloferon in particular, should be used in combination with ribavirin when a chronic hepatitis C patient with the extrahepatic manifestations of HCV infection has contraindications to conventional therapy with recombinant interferon-α.

[Metabolic correction of dyslipidemia in patients with nonalcoholic fatty liver disease as a new therapy policy].

AIM: To study the impact of infusion therapy with the metabolic modulator remaxol on lipid metabolic parameters and target organ (liver, kidney) function in metabolic syndrome (MS). SUBJECTS AND METHODS: The investigation enrolled 90 patients (54 men and 36 women) with primary nonalcoholic steatohepatitis that was associated with insulin-resistance and MS; their age was 21 to 77 years. Every day the study group patients (n = 50) took as a component of combination therapy the metabolic hepatoprotective modulator remaxol intravenously in a dropwise manner in a dose of 400 ml once daily; the comparison group patients (n = 40) received ademetionine 400 mg diluted in 400 ml of isotonic sodium chloride. The duration of infusion therapy was 11 days. RESULTS: Infusion therapy with remaxol caused a pronounced blood lipid composition-regulating effect, by reducing the level of major atherogenic lipids (total cholesterol, triglycerides) and improving liver function and renal nitrogen-excreting and filtration function in patients with Stage IV diabetic nephropathy in the presence of MS. CONCLUSION: Therapy with the metabolic hepatoprotective modulator remaxol ensures reliable metabolic control and multifactorial correction of risk factors of organ lesions in MS: cardio-, hepato-, and nephroprotection.

[Comparative efficacy of etiotropic therapy of patients with HBeAg-positive chronic hepatitis B (by the data of the international comparative placebo-controlled study)].

Comparative placebo-controlled study entrolled 647 patients with verified diagnosis of chronic virus hepatitis B (HBeAg+), not previously subjected to antiviral therapy (with nucleotide analogues or interferons). The drug under the investigation was cycloferon, an earlier interferon inductor. The antiviral combination therapy of the main group patients (323 subjects) included the use of cycloferon + lamivudine for 48 weeks and the therapy of the control group patients (324 subjects) included the use of lamivudine + placebo for 48 weeks. The cycloferon and lamividine combination antiviral therapy was shown preferable vs. the lamivudine + placebo therapy by biochemical remission, virusological response, seroconversion by HBeAg by the 48th week of the treatment and HBsAg clearance. The conbination therapy provided lower frequency of the relapses within 24 weeks of the observation. The higher efficacy of the antiviral combination therapy was evident of the impact of the antiviral activity of cycloferon itself and its immunomodulating and interferon-inducing activity on elimination of the virus-infected hepatocytes. The use of the 48-week course of the antiviral combination therapy is advisable as the prime treatment in the management of patients with HBeAg-positive chronic hepatitis not previously treated with nucleoside analogues and as a variant of therapy for lamivudine-refractory patients.

[Pathogenetic therapy of metabolic syndrome at the stage of visceral lesions].

Insulin resistance and oxidative stress play an important role in the pathogenetic mechanism of non-alcoholic fatty liver disease. Hepatoprotective therapy that blocks the second phase of pathogenesis (oxidative stress) is a promising modality for the treatment of non-alcoholic steatohepatitis (NACH). An alternative approach is the use of medicines recovering the mitochondrial membrane, lipid bi-layer of the plasma membrane, oxidative phosphorilation, and cellular metabolism. In this context, succinic acid-based remaxol showing antioxidative, antihypoxic and cytoprotective activities can be regarded as a promising metabolic hepatoprotector for the treatment of non-alcoholic fatty liver disease. The present original study demonstrated the clinical efficacy of remaxol in pathogenetic therapy of NACH in patients with metabolic syndrome. Its introduction in the combined treatment of NACH increased functional capacity of the liver by decreasing the severity of cytolysis, cholestasis, hepatomegalia, and steatosis (ultrasonic study), improved lipid metabolism, reduced cholesterol level, triglyceridemia, and atherogenic index. Remaxol exerted nephroprotective action in patients with diabetic nephropathy at stage 1 of chronic renal insufficiency (increased glomerular filtration rate and decreased blood creatinine level). The study demonstrated the advantage of medications with antihypoxic properties over traditional therapy of NACH.

[Metabolic correctors based on succinic acid as pathogenic therapy in chronic virus hepatitis].

Chronic viral hepatitides (CVH) run with long-term activation of the system of mononuclear phagocytes associated with hyperproduction of active oxygen forms. This can be considered as risk factors of antioxidant insufficiency which determines the course of the disease. Now, antioxidant, cytoprotective medicines are more and more actively used in hepatology. The results are reviewed of many Russian clinical trials of efficacy of metabolic correctors based on siccine acid (reamberin, remaxol) as pathogenetic treatment in CVH. Metabolic correctors in combined treatment of CVH improve basic clinico-laboratory indices, raise efficacy of basic therapy, correct insufficiency of antioxidant defense. The results of the studies confirm advantage of antihypoxic medication over standard infusion therapy for treatment of CVH patients.

[Rate of identification and characteristic of Streptococcus pneumoniae isolated from carriers and ill children in Khabarovsk region].

AIM: To assess the role of nasopharyngeal and clinical strains of Streptococcus pneumoniae in respiratory disease of children. MATERIALS AND METHODS: Two hundred and fifty-eight children attending and not-attending daycare as well as 1292 children with respiratory diseases admitted to clinic of Research Institute of Maternity and Childcare during 2001-2009 were studied. Materials for study were pharyngeal swabs and sputum. Identification was performed using optochin disks (bioMerieux), latex-agglutination (Slidex meningo-kit, bioMerieux) and agglutination on the glass. Fragment of S. pneumoniae genome was determined by PCR using diagnostic kits GenePac Spn (IsoGen Ltd., Moscow). RESULTS: Level of nasopharyngeal carriage of pneumococci is increased in children with recurrent respiratory illnesses as well as in children closed communities of children. Strains isolated from nasopharynx were typical on morphological and tinctorial characteristics and have increased level of resistance to macrolides and decreased level of resistance to penicillin compared to clinical strains of which 15-20% were optochin-resistant. CONCLUSION: Local serological spectrum of pneumococci circulating in Khabarovsk region was determined, which includes 13 serovariants with predominance of serotypes K1, K19, K6.

[Integral index of body functional response of adolescents from Khabarovsk region under conditions of chronic malnutrition].

Incomplete chronic substrat-energetic unsufficiency, connected with protein-fat difficiency of daily rations is revealed 13-17 year old in habitants of Khabarovs region (both natives and non-natives). The unsufficiency is majority revealed in native teenagers is combination with a feebly revealed adaptive reactions on bower levels of integral index of organisms functional response.

[Etiology of acute and chronic pyelonephritis in children in Khabarovsk region].

Microflora of urinary tract was studied in 419 children aged 1 - 17 years and hospitalized due to acute or chronic pyelonephritis. Etiology of inflammatory process was established in 57.8% of cases. According to our study, etiologic structure of causative agents of pyelonephritis did not differ from all-Russian data. The leading positions belonged to Gram-negative microorganisms from Enterobacteriaceae family: Escherichia coli, Proteus mirabilis, and Klebsiella spp. Results of the study point to high susceptibility of main causative agents of pyelonephritis to cephalosporins, aminoglycosides, and fluoroquinolones. High resistance to aminopenicillines was noted. In several isolates from Enterobacteriaceae family significant resistance to nalidixic acid and furazidin was observed.

[Etiology of pulmonary diseases in children in Khabarovsk Region].

Microflora of upper respiratory tract in 658 children aged 1 month - 17 years hospitalized with acute pneumonia (AP), acute bronchitis (AB), recurrent obstructive bronchitis (ROB), malformation of lungs (ML) and broncho-alveolar dysplasia (BALD) were studied. Carriage rates of Streptococcus pneumoniae (up to 95%) and Haemophilus influenzae (up to 89%) in 240 children attending daycare centers and schools were determined. Etiology of infectious process was ascertained in 40% of cases. S. pneumoniae was isolated in 45% of acute cases (AP and AB) and in 25% of chronic cases (BALD). H. influenzae was isolated in 8 - 12% of acute cases and in 32% of chronic cases. In 23 - 29% of all cases of pulmonary pathology in children persistence of Enterococcus faecium was determined. There were 13 different serotypes among isolated pneumococci. In patients with pneumonia the rate of detection of S. pneumoniae and H. influenzae DNA fragments by PCR was significantly higher compared with rate of their isolation from sputum.

[Immunopathogenesis of severe wounds and traumas: possibilities of immune correction]. / Immunopatogenez tiazhelykh ranenii i travm: vozmozhnosti immunokorrektsii.

The authors describe the present-day views on the nature of immune dysfunctions in severe traumas. Based on personal clinical experiences and literature data the authors discuss the role of immune dysfunctions in pathogenesis of the traumatic disease. Special attention is given to the role of the immune system in the development of the life-threatening condition: polyorganic insufficiency whose formation mainly results from disorganization and functional failure of the system of immune reactivity. Clinical investigations have shown high effectiveness of early administration for severe wounds and traumas of a new means of immunocorrection--yeast recombinant interleukin-2 of man (preparation Roncoleukin). The administration of this immunocorrector in complex schemes of intensive therapy of the victims was shown to prevent the development of severe pyo-septic pathology and perfectly change the course of the traumatic disease.