[The follow-up results of patients with necrotic suppurative forms of diabetic foot syndrome].

Follow-up results of 162 patients with necrotic suppurative forms of the diabetic foot syndrome (DFS) are studied in a period of 6 months to 7 years. 51.35% of patients with neuropathic form of DFS (NPDFS) relapsed, whereas among patients with neuroischemic form (NIDFS) relapse was reported in 61.36% of cases. High amputations were performed in 31.58% of patients with NPDFS and in 34.09% in patients with NIDFS. Lethality after five years of follow-up was 25.81% after shank-level amputation and 50% after hip-level amputation in patients with NPDFS, and in the group of NIFDS these numbers amount 57.84% and 72.12%, respectively. Authors conclude that compensation of diabetes and its late complications is crucial for patients with DFS. Surgical treatment should be maximal sparing, with possible foot preservation. Vascular reconstructive surgery should be preferred in NIDFS for critical limb ischemia reduction. The level of high limb amputations in patients of both groups should be limited by shank when possible.

[Surgical tactics in treatment of osteomyelitis of long bones].

The new osteomyelitis classification was worked out on the strength of treatment results of 361 patients. Four types of long bones lesions are marked out: medullar, superficial, focal and diffuse. The kind of surgical treatment is determined according to the lesion type. Authors worked out a modification of osteoplastic trepanation--a "grip-sack" technique, which is used for medullar and focal femoral and tibial osteomyelitis. Long term follow-up results are obtained in 271 (77,7%) cases. The developed classification eases the standardization of follow-up results and permits treatment planning.

[Modern approach to treatment of trophic ulcers of legs with perifocal varicose eczema, associated with mycotic infection].

During 2005-2007 128 patients at the age from 21 to 80 years with extensive trophic ulcers of legs were treated in the contaminated surgery department of A.V. Vishnevsky Surgery Institute and Korolenko Hospital. In 87 patients (69.9%) varicosity was the cause of venous insufficiency, in 41 patients--post-thrombotic disease. 23 patients (17.97%) had double-sided throphic ulcers. In 50 patients (39.1%) ulcer area exceeded 40 cm2. In microscopical analysis fungi were discovered in 87 patients (89.06%). In the remaining 15 patients diagnosis was verified culturally. System etiotropic antimycotic antibacterial treatment including hyposensitizative, anti-inflammatory, antihistamine drugs was carried out. 34 patients (26.57%) received broad spectrum antibiotic from terbinafine group (Terbizil) in dosage 250 mg once a day during 3 moths with concurrent use of topical antimycotics. 34 patients (26.56%) recieved pulse therapy with broad spectrum antibiotic Rumicoz 400 mg a day during 7 days in combination with topical antimycotics. Nizoral 400 mg a day during 30 days was prescribed to 26 patients (20.3%). 34 patients (26.56%) were treated only with topical antimycotics. After preoperative preparation and reduction of inflammatory process 64 patients had underwent excision of trophic ulcers whereupon the therapy was continued. In these patients regress of varicose eczema manifestation was achieved on the 10th day. In patients who hadn't received surgical cure regress of varicose eczema was signed on the 23-25th day after onset of treatment. Question of plastic closing of throphic ulcers and wounds after their excision was solved particularly. 14 patients needed recurring surgical management becose inflammatory process was continued. Comprehensive approach to therapy taking into account mycotic semination appears to be appropriate and effective. Proactive surgical tactics (excision of throphic ulcer) allows to quicken preoperative preparation for correction of venous blood flow.

[Hemostasis system disturbances and their correction in patients with pyonecrotic forms of diabetic foot].

Severe hypercoagulation syndrome was diagnosed in patients with various forms of diabetic foot. Pathology at coagulogram parameters reflects systemic metabolic and inflammatory disturbances. Anticoagulant therapy should be combined with correction of glycemia, treatment of infection and critical ischemia. Only this complex therapy can normalize coagulation parameters and reduce the risk of thrombotic complications.

[Clinical importance of early diagnosis of anaerobic non-clostridial infection].

Anaerobic infection is one of the most complicated problems of pyosurgery. The algorithm of examination of patients with anaerobic infection including intraoperative diagnosis is proposed. Surgical treatment playing also diagnostic role is the basis of combined treatment of soft tissues anaerobic infection. Early diagnosis and active surgical policy is one of the main ways of problem solving.

[Endoscopic subfascial dissection of venous perforants in treatment of venous trophic ulcers of the legs].

Endoscopic subfascial dissection was performed in patients with chronic venous insufficiency of CEAP class 4-6. 76 surgeries were performed in 68 patients. Mean age of the patients was 56 years. The causes of chronic venous insufficiency were varicose (37) and postthrombotic diseases. Trophic ulcers were in 46 patients. Thirty patients underwent earlier various phlebectomies, including Linton's surgery (6 patients). In 33 patients endoscopic subfascial dissection of venous perforants was combined with various phlebectomy, in 37 patients -- with excision of ulcer with following autodermoplasty few days after surgery. Endoscopic subfascial dissection was carried out with special surgical R.Wolf endoscope with 6 mm instrumental canal, and also standard laparoscopic optical devices "Olympus". Complications during surgery were seen in 2 patients: bleeding in subfascial space (1.3%) and perforation of tissues in ulcer zone (1.3%). In postoperative period long (up to 14 days) lymphorrhea and suppuration of surgical wound were in 2 (2.6%) patients. It is concluded that endoscopic approach is optimal for elimination of pathological reflux through venous perforants in complicated forms of chronic venous insufficiency of the lower extremities, including trophic ulcers resistant to treatment.

[Staged tissue expansion in the surgery of suppurative wounds]. / Dozirovannoe tkanevoe rastiazhenie v gnoinoi khirurgii.

To close extensive infected wounds and to replace long bone defects, along with other methods a method of graded tissue strain (GTS) has been developed and introduced into practice (246 patients). The method differs from all others in that it requires no transfer of elaborate flaps while replacing soft tissue defects; and no graft or foreign body is introduced externally into the wound in replacing long bone defect. Soft tissue defect is gradually replaced by wound-adjacent intrinsic tissues, the wound is closed by related skin and bone defect is filled by an osseous regenerate which is formed during graded transposition of the osteotomized fragment. At the same time good blood supply and tissue innervation retain, which contributes to their resistance to purulent infection. The analysis of the findings has led to the conclusion that GTS is an indispensible contribution to the development of plastic purulent surgery allowing the anatomic and functional integrity of the diseased segment to be restored.

[Neutrophilic respiratory response in surgical infection and an association with plasma membranous synthesis of ATP]. / Respiratornyi otvet neitrofilov pri khirurgicheskoi infektsii i sviaz' s plazmamembrannym sintezom ATP.

Early studies have demonstrated that the unique phenomenon ATP aerobic synthesis on neutrophilic plasma membranes is observed when neutrophils are activated with the chemoattractive peptide FMLP. This paper presents the results of the study of a possible association of ATP plasma membranous synthesis with priming, with the occurrence of respiratory explosion and apoptosis of the neutrophils isolated from the blood of donors and patients with surgical infection of different severity. The interaction of neutrophilic plasma membranes with FMLP and with hTNF (was attended by ATP synthesis. Examining the level of FMLP-stimulated production of superoxide in patients with surgical infection revealed that the amount of the superoxide produced by neutrophils noticeably decreased and droppped by more than 5 times in sepsis. The FMLP-stimulated plasma membranous synthesis of ATP was determined in the same patients. A decrease in the production of superoxide was simultaneously accompanied by a reduction in the plasma membranous synthesis of ATP. Both the plasma membranous synthesis of ATP and the production of superoxide declined in sepsis at the most. The neutrophils isolated from peripheral blood of the same patients showed DNA damage whose degree was directly related to the condition of a patient. The maximum DNA damages were observed in sepsis. The findings suggest that apoptosis is induced in surgical infection in the peripheral neutrophils. The DNA damage and the FMLP-stimulated plasma membranous synthesis of ATP was estimated in the neutrophils isolated from the inflammation focus. It turned out that in local surgical infection, there were the maximum DNA damages and the FMLP-stimulated plasma membranous synthesis of ATP was lower than that in the peripheral neutrophils. It can be suggested that the FMLP-stimulated plasma membranous synthesis of ATP may be a regulators of neutrophilic functional states in surgical infection and sepsis.

[An electron radioautographic study of the vessels in the granulation tissue of long-term nonhealing wounds]. / Elektronno-radioavtograficheskoe issledovanie sosudov granuliatsionnoi tkani dlitel'nogo ne zazhivaiushchikh ran.

The wounds without healing for a long time (from 1 month to 2 years) were studied histologically and electron-radioautographically. The reduction of the vessel number in such wounds occurs, first, due to degenerative changes in the cells of their walls, and second, due to loss of connection between the cells. Some of these cells retain functional activity (incorporation of 3H-uridine) and capacity for proliferation (incorporation of 3H-thymidine). The latter is particularly characteristic for pericytes, this proving their role as a source of fibroblasts in the stage of organization and formation of the scar.

[Electron microscopic study of the blood in suppurative wounds complicated by sepsis and bacterial shock]. / Elektronno-mikroskopicheskoe issledovanie krovi bol'nykh s gnoinymi ranami, oslozhnennymi sepsisom i bakterial'nym shokom.

Electron microscopic examinations of the white blood in 7 patients with purulent wounds and clinical manifestations of sepsis and in 1 patient with purulent wounds complicated by the development of bacterial shock as well as of the ultrastructure of bacteria isolated from the wound content of the patients were carried out. The controls consisted of electron microscopic examinations of the blood from two donors. The blood of patients with sepsis was found to contain free microbial cells and those phagocytized by neutrophilic leukocytes. Free bacteria formed large colonies enveloped in a strong membrane in the blood. Some leukocyte-phagocytized microbes underwent lysis, the others, surrounded by an envelope were located in large vacuoles in the blood cell cytoplasm (incomplete phagocytosis). Numerous microbial cells both free and phagocytized were particularly frequently found in bacterial shock accompanied by the clinical picture of most acute septicemia.

[Blood neutrophilic leukocytes in patients with suppurative-septic diseases]. / O sostoianii neitrofil'nykh leikotsitov krovi bol'nykh gnoino-septicheskimi zabolevaniiami.

Neutrophil leucocytes of patients with sepsis, purulent inflammatory processes clinically close to sepsis and those of healthy persons were studied electron-microscopically. Leucocytes with degranulation due to the release of their content into the circulation were found in purulent-inflammatory diseases. Leucocytes with pronounced degranulation, areas with cytoplasma lysis and extracellular organelles (lipid droplets, primary and secondary granules with clear-cut membrane borders and content of granules without membrane borders) were observed in sepsis.

[A morphological and electron radioautographic study of the wound in the diabetic foot syndrome]. / Morfologicheskoe i élektronno-radioavtograficheskoe izuchenie rany pri sindrome diabeticheskoi stopy.

Two groups of patients with a grave form of diabetes mellitus type I and II with diabetic foot syndrome have been examined. Group 1 (21 cases) consisted of patients whose foot was amputated. The cause of the necrotic process was ischemia produced by alteration of the arterial vessels aggravated by infection. Patients of group 2 (18 cases) were treated with resultant wound healing and foot preservation. The material was subdivided into two subgroups: 1) tissue from the "infectious" foot with great amount of bacteria and inflammation reaction; 2) tissue from the "ischemic" foot with considerable alterations of microvessels structure. In both groups well developed granulation tissue was observed after the treatment; almost all the cells of this tissue included 3H-uridin and labelling with 3H-thymidine was increased in fibroblasts, endotheliocytes and pericytes.

[Use of a new drug, lomefloxacin (maxaquin), from the fluoroquinolone group in the treatment of patients with wound infection]. / Primenenie novogo preparata iz gruppy ftorkhinolonov lomefloksatsina (maksakvina) pri lechenii bol'nykh s ranevoi infektsiei.

A clinicolaboratory study on the efficacy of lomefloxacin (maxaquin, Searle, USA) was carried out in the treatment of 31 patients with wound infections. In the complex therapy the clinical efficacy of the drug amounted to 96.7 per cent and its bacteriological activity reached 64.6 per cent. The drug tolerance in the majority of the cases was good. Only in one patient an allergic reaction in the form of multiple skin eruption on the 6th day of the treatment was recorded. One patient showed an insignificant increase in the level of alanine aminotransferase not accompanied by any signs of hepatic insufficiency.

[Use of a combination of cefoperazone with sulbactam for treatment of patients with wound infections]. / Primenenie kombinatsii tsefoperazona s sul'baktamom dlia lecheniia bol'nykh s ranevoi infektsiei.

The clinical efficacy of sulperazone (cefoperazone + sulbactam) manufactured by Pfizer (USA) was studied in the treatment of 25 patients with wound infections. By the disease severity and complications 9 patients belonged to the risk group. Insulators with abacterial media or bandages with ointments on the polyethylene glycol base and drugs stimulating reparative processes (methyl-diadioxylin, dioxyzol, gentacycol) were used for the local treatment of the wounds. The clinical efficacy was stated in 92 per cent of the cases and in 76 per cent of the cases the efficacy was bacteriological. The tolerance of sulperazon was good in all the cases. The signs of the drug intolerance or affection of the hepatic or renal function were not detected. 281 clinical isolates of the aerobic microflora were tested for their antibiotic susceptibility. The highest susceptibility to sulperazone was observed in gram-positive organisms, gram-negative bacilli (Proteus mirabilis, Escherichia coli and Klebsiella spp.) and some nonfermenting bacteria.

[Clinico-laboratory study of piperacillin/tazobactam in the treatment of patients with would infection]. / Kliniko-laboratornoe izuchenie piperatsillin-tazobaktama pri lechenii bol'nykh s ranevoi infektsiei.

Piperacillin/tazobactam (P/T) or tazocin was used in the treatment of 40 patients with soft tissue purulent necrotic wounds of various genesis and localization. In the majority of the patients the affection was of recurring nature. P/T was administered in a dose of 4.5 g 3 times a day for 1 to 14 days (mainly for 8 to 10 days) as 30-minute intravenous infusions. The clinical effect of the treatment was stated in 36 patients (90 per cent). In 3 out of 8 patients with diabetes mellitus the treatment failed. In 1 patient the treatment was discontinued after the first dose because of asphyxia and a short-term decrease of the arterial pressure. Among 105 microbial strains isolated from 75 patients 64 were highly susceptible to P/T, 33 were moderately susceptible and 8 were resistant. 76.3 per cent of the isolates produced beta-lactamase, 66.3 per cent of them were susceptible to P/T. 54 gram-positive and gram-negative strains were isolated from 40 patients. 16 out of the 54 strains were isolated as monocultures and the others as associations. After the treatments the pathogen eradication and the pathogen eradication followed by superinfection were stated in 26 patients (66.7 per cent). In 11 patients (28.2 per cent) the pathogen persistence was observed at the background of the clinical improvement in the majority of the patients. The relapses were recorded in 2 patients (5.1 per cent).

[Ten-year experience with the use of ofloxacin in the treatment of wound infection]. / Desiatiletnii opyt ispol'zovaniia ofloksatsina pri lechenii ranevoi infektsii.

The experience with ofloxacin used for 10 years from 1986 to 1995 in the complex therapy of 208 patients with wound infection complicated in 51 patients (24.5 per cent) by respiratory tract infection such as purulent tracheobronchitis or pleuropneumonia was generalized. In 28 patients (13.5 per cent) persistent bacteriuria not susceptible to the routine drugs was stated. The clinical and bacteriological efficacies of ofloxacin in the group of the patients with noncomplicated purulent wounds of the soft tissues amounted to 85-91 and 74-80 per cent respectively. In the group of the patients with wound infection complicated by respiratory or urinary tract infection the clinical and bacteriological efficacies equaled 94-100 per cent. The appetite disorder, epigastric pain or nausea were rare. Only in 3 cases the adverse reactions required the treatment discontinuation. Despite the use of ofloxacin for many years, the susceptibility of the main causative agents of surgical infections to the drug remained high: Staphylococcus epidermidis 93.3 per cent, Staph.aureus 94.5 per cent, Pseudomonas aeruginosa 96.5 per cent, Escherichia coll 100 per cent, Proteus spp. 100 per cent, Enterobacter spp. 100 per cent, Acinetobacter spp. 82.3 per cent and Klebsiella spp. 88.8 per cent. The successive use of ofloxacin, at first intravenously for 3-5 days and then orally in the form of tablets for 3-5 days, in the treatment of 15 patients with wound infections of various genesis and localization subjected to osteoplastic reconstructive operations provided positive effects in all the cases and was economically advantageous.

[Microflora of purulent necrotic leisions of the foot in patients with diabetes mellitus]. / Mikroflora gnoino-nekroticheskikh porazhenii stopy u bol'nykh sakharnym diabetom.

Microflora of purulent necrotic lesions of the foot in 14 patients with diabetes mellitus was investigated by aerobic and anaerobic procedures. It was shown that the process was due to the same species of pathogenic microorganisms irrespective of the lesion severity. However, the number of the pathogens in the associations and the dissemination level per a patient were higher when the lesions were extended. The tissue microbial dissemination in the purulent foci was also higher in the patients with wounds complicated by marked inflammation of the surrounding tissues and the tissues under the lesion. The time course of the changes in the foot microflora during the target-aimed antibacterial therapy was followed up.

[Clinico-laboratory effectiveness of modern ointments with a polyethylene glycol base in the treatment of purulent wounds]. / Kliniko-laboratornaia éffektivnost' sovremennykh mazei na poliétilenglikolevoi osnove pri lechenii gnoinykh ran.

The 25-year experience with the underbandage treatment of soft tissue purulent wounds of various location and genesis with modern ointments with polyethylene glycol as the basis was analyzed. Levocin, levomecole, dioxycole, 5-percent dioxydinic, 1-percent iodopyronic, 0.5-percent quinifuryl and furagel ointments proved to preserve their high activity against aerobic grampositive and gramnegative flora. 10-percent mafenide acetate ointment had a high selective effect on Pseudomonas aeruginosa. The new ointments nitacid and streptonitole containing nitazole and white streptocide were highly active against both aerobic and anaerobic infections. The use of the ointments with the polyethylene glycol as the basis made it possible to decrease 2 times the period of the patient hospitalization in surgical units and to shorten the terms of the systemic antibacterial therapy. The marked therapeutic effect of such ointments due to their high dehydrating capacity and broad antibacterial spectrum enabled to consider them as the drugs of choice in the local treatment of purulent wounds during the 1st phase of the wound process, trophic and decubic ulcers, infected burns, diabetic and atherosclerotic gangrene, furuncles, carbuncles, mastitis, etc. The ointments in the water soluble vehicle can be as well used with success for the prophylactic treatment of infected wounds after the suture. The multitarget effect of the ointments in the water soluble vehicle and their ability to prevent severe purulent complications permitted to consider them as the 1st order drugs in cases of emergency.

[Method of estimation of lysozyme activity in serum with chitin azure as substrate]. / Metod opredeleniia aktivnosti lizotsima v syvorotke krovi s ispol'zovaniem v kachestve substrata khitinazura.

The method of estimation of lysozyme activity in serum when chitin azure is used as substrate is described. The basis of incubation medium is 0.1 M acetate buffer, pH 5.0. It was judged about activity of lysozyme by fluorescence of azure in incubation medium at the end of three hour incubation at 37 degrees C after separation on non-reacted chitin azure by short time centrifugation. It was shown that development of wound infection is accompanied by increasing of chitinase activity of lysozyme in serum.

[Use of cefpirome in the treatment of patients with skin and soft tissue infections]. / Primenenie tsefpiroma pri lechenii bol'nykh s infektsiiami kozhi i miagkikh tkanei.

The efficacy of cefpirome was estimated in the treatment of 25 patients: 15 patients with pyo-necrotic wounds of the soft tissue of various genesis and localization and 10 patients with deep thermal burns involving 8 to 40 per cent of the body surface. The clinical and bacteriological efficacies of the treatment in the patients with the wound infection amounted to 100 and 80 per cent respectively. In the patients with the burn infection the respective values were 90 and 80 per cent. The drug tolerance was good. Adverse reactions were observed in 1 patient. Bolus intravenous administration of the drug was preferable by comparison with the injections.