[Pulmonary artery thrombosis: strategy of anticoagulation]. / Tromboz legochnoi arterii: taktika pri vybore antikoagulyantnoi terapii.

This review is devoted to the management of primary artery thrombosis (PAT). This disease was always considered only as a part of other venous thromboembolic events, in particular isolated pulmonary embolism (PE). Various studies show that PAT can develop as an independent event without concomitant damage to extra-vessels. PAT is characterized by own typical signs as primary and recurrent event that can determine special strategies of treatment. However, there are no studies devoted to this problem. We can only make some assumptions about PAT anticoagulation (AC) considering data on isolated PE comprising PAT. These data are available in PADIS-PE, ASPIRE, EINSTEIN-PE, Hokusai-VTE studies underlying modern guidelines of various societies. In the absence of studies on PAT AC these guidelines should regulate PAT AC approaches. AC is recommended in all cases of PE except isolated subsegmental PAT in ambulatory patients. Duration of AC depends on risk factors (major or minor). Anticoagulation for PAT following chronic inflammatory diseases is still disputable.

[Clinical efficacy of electric stimulation of crural muscles in comprehensive treatment of post-thrombotic disease]. / Klinicheskaia éffektivnost' élektricheskoi stimuliatsii myshts goleni v kompleksnom lechenii posttromboticheskoi bolezni.

The purpose of the study was to evaluate clinical efficacy of electromyostimulation (EMS) of the crural muscles as part of comprehensive therapy for post-thrombotic disease in patients with residual venous obstruction in the femoropopliteal segment. We carried out a prospective comparative clinical study enrolling patients having endured a fist episode of clinically unprovoked venous thrombosis of the femoropopliteal segment and completed the standard 6-month course of anticoagulant therapy and presenting with ultrasonographic signs of complete recanalization of the proximal venous segments (stenosis of 20% and more from the vessel's initial diameter), as well as scoring 5 points and more by the Villalta scale. The study included a total of 60 patients (38 men and 22 women, mean age 58.5±11.4 years) subdivided into two groups consisting of 30 patients each. Patients of both the Study and Control Groups underwent comprehensive therapy including wearing a compression knee sock (23-32 mmHg), a course phlebotrophic drugs, and dosed walking (not less than 5,000 steps a day). The Study Group patients were additionally subjected to daily electrical stimulation of the crural muscles with the "Veinoplus VI" unit (three 30-minute sessions a day). The duration of the follow up amounted to 12 months. The criteria for assessing therapeutic efficacy were as follows: severity of the disease by the VCSS and Villalta scales, quality of life as assessed by the CIVIQ-20 questionnaire, and lack of relapses of the venous thrombus. Clinical and instrumental assessment of the patients' condition was carried out monthly, with the disease's severity and quality of life assesses each 6 months. Relapses of venous thrombosis were registered in 7 (23.3%) patients from the Control Group and were not observed in patients undergoing EMS (p=0.011). In 5 cases, thrombosis was asymptomatic and in 4 cases it was presented by reocclusion of the involved venous segments. Patients of the Study Group were found to have a decrease in the disease's severity, reflected in points: VCSS (9.9±1.6 - 7.8 ± 1.6 - 6.1±1.5 (p <0.0001)); Villalta scale (18.9±3.9 - 12.8±4.0 - 8.3±2.7 (p<0.0001)); CIVIQ-20 score (67.8±8.4 - 51.3±8.4 - 40.0±10.5 (p<0.001)). The Control Group patients showed a similar tendency for the disease's severity: 8.1±2.8 - 7.3±2.1 - 7.2±2.1 points by the VCSS (p=0.014); 12.7±6.7 - 10.9±5.6 - 10.2±5.4 points by the Villalta scale (p=0.002), but not for quality of life: 48.2±19.3 - 46.7±17.3 - 47.4±16.2 points by the CIVIQ-20 (p>0.05). On the background of using EMS, the alterations in the studied parameters were characterized by higher velocity and intensity (p<0.05). The use of electromyostimulation as part of comprehensive treatment for post-thrombotic disease makes it possible to efficiently eliminate both subjective and objective signs of venous insufficiency, improve patients' quality of life and decrease the risk for the development of relapsing venous thrombosis.

[Role of compression bandage with elevated level of pressure in decreasing incidence of venous thrombosis in high-risk patients].

UNLABELLED: The study was aimed at assessing efficacy and safety of using graduated compression bandage with the level of pressure in the area of the middle ankle amounting to 20-40 mm Hg as compared to the conventional profile (10-20 mm Hg in the ankle area) in the composition of comprehensive prevention of postoperative venous thromboembolic complications (VTEC) in patients of a high-risk group. For this purpose we carried out a prospective randomized clinical study including a total of 100 surgical patients (general surgery, neurosurgery) from a group of high risk for the development of VTEC with the presence of 3 and more conditions predisposing to venous thrombosis. All patients were subdivided into two subgroups 50 patients each. Patients in both groups received anticoagulants in standard preventive doses from the first day after surgery or in the remote period. The Study group patients were treated by applying on the ankle a bandage of medium distensibility with the target pressure in the ankle area of 20-40 mm Hg measured by means of a portable manometer. The control group patients were treated by a similar bandage applied onto the ankle and femur with a pressure of 10-20 mm Hg. In all cases a special lining material was placed under the bandage. With the purpose of active screening of postoperative VTECs, prior to the beginning of the study and then each 3-5 days we performed ultrasound angioscanning and in case thrombosis was revealed we performed static perfusion scintigraphy of the lungs and/or echocardiography for verification of pulmonary embolism. The patients who died were subjected to post-mortem examination. We also assessed the frequency of correcting the bandage on the femur and crus. RESULTS: The incidence rate of postoperative venous thrombosis in the Study Group amounted to 16.0% (95% CI: 5.8-26.2%) and in the Control Group 36.0% (95% CI: 22.7-49.3%, p=0.039), with no significant differences in the incidence of proximal thrombosis or pulmonary embolism revealed. Maximal reduction of the development of venous thrombosis was revealed in patients with lower-limb paralysis amounting to 69.5%. The frequency of the development of cutaneous lesions under the bandage did not differ significantly between the subgroups, being 8% and 12%, respectively. The total number of corrections of the compression in the Control Group was significantly higher, amounting to 0.64±0.23 time a day versus 0.32±0.05 t/d (p<0.0001). CONCLUSION: The use of an elevated compression profile makes it possible to decrease the incidence of postoperative VTECs, especially in patients with palsy, not increasing the rate of cutaneous lesions under the bandages. Femoral compression provides no additional reduction of the incidence of thrombosis but creates an additional necessity of correcting the bandages.

[Caprini score as individual risk assessment model of postoperative venous thromboembolism in patients with high surgical risk].

The aim of this study was to estimate the role of Caprini model in forecasting of postoperative venous thromboembolism (VTE) in patients with high surgical risk and to determine patients with extremely high risk of venous thrombosis by using of this scale. It was performed prospective multicenter observational study involving 140 high risk patients who underwent large abdominal (48%) or neurosurgical (52%) intervention. All patients were assessed with the Caprini model and had a mean score of 9.5±2.7 (range: 5-15). Complex postoperative prevention of venous thromboembolic complications included elastic compression of low extremities and standard prophylactic doses of direct anticoagulants. Duplex ultrasonic scanning was performed during the first 12 hours after surgery and then every 3-5 days until discharge to assess the lower limbs venous system. If venous thrombosis was observed pulmonary embolism has been excluded by using of echocardiography, planar perfusion scintigraphy of the lungs, SPECT-imaging with computed tomography. Venous thrombosis was diagnosed in 39 (28%) patients. The incidence of VTE was 1.9% in the lowest tertile of the Caprini score (5-8); it was 26.1% in the middle tertile (score 9-11) and 65% in the upper tertile (score 12-15) (p<0.001). The area under ROC curve was 0.874 (95% CI 0.81 to 0.94) and Caprini score 11 was a cut-off point that provided the highest sensitivity and specificity. 2 (2.6%) of 77 patients with score less than 11 had venous thrombosis. In contrast, 37 (58.7%) of 63 patients with Caprini score 11 and more had venous thrombosis (p<0.001). There is significant correlation between Caprini scores and frequency of postoperative venous thromboembolism in patients with high surgical risk. Score 11 and more can identify patients with extremely high risk. These patients need for more effective prevention.

[Epidemiology of venous thromboembolias among the high risk surgical patients and the role of sural sinus in initiation of thrombus formation].

The prospective study of postoperative venous thromboembolism after standard prophylactic measures among high risk patients was performed. The ultrasound lower limb veins investigation registered postoperative venous thrombosis in 32.7% of these patients, the proximal thrombosis was in 9.1%. Half of the cases demonstrated the isolated sural sinus thrombus and the overall sural sinus involvement was 83.3%. 50% of all thromboses were diagnosed within the first week after the operation. 86.1% of all cases were registered within 2 weeks after the surgery. Terms of anticoagulative drugs prescription showed no influence on the thrombosis incidence aiming the researched patients. The study demonstrated the high true incidence of postoperative venous thromboembolism after standard prophylactic measures among high risk patients and the leading role of the sural sinus in its initiation.

[Haemodynamic and clinical efficacy of electric muscular stimulation of the venous outflow in prevention of postoperative venous thromboembolic complications].

The present clinical and experimental study was carried out in order to evaluate efficacy of electrical stimulation of the crural muscles with the purpose of preventing postoperative venous thromboembolic complications. At the first stage by means of ultrasonographic angioscanning in apparently healthy volunteers (n=21) we evaluated the linear velocity of blood flow on the popliteal vein on the background of using myostimulation and compression bandage with various levels of pressure applied either separately or in a combination with each other. It was revealed that electrical stimulation of the crural muscles led to a 2.8-4.5-fold increase in the peck velocity of blood flow, while the compression decreased the parameters of the venous outflow both at rest and during muscular contraction. By means of theoretical calculations it was determined that an optimal compression profile for a combination with electrical stimulation is a pressure under the bandage equalling 20-40 mm Hg, providing substantial acceleration of the venous outflow with the laminary blood flow preserved. At the second stage we assessed efficacy of comprehensive prevention of venous thromboembolism with the use of electromyostimulation, the respective compression bandage and direct anticoagulants in surgical-profile patients from a high-risk group (n=90) by means of ultrasound screening of the venous system during the whole postoperative period. When myostimulation was used in the regimen of 3-5 procedures a day, the frequency of venous thrombosis amounted to 40% (n=10) and did not significantly differ from that in patients not subjected to myostimulation (25%, n=40). When myostimulation was used in the regimen of 5-10 procedures per day, the frequency of venous thrombosis turned out to be considerably lower (2.5%, n=40). A conclusion was made on efficacy of using this method in the examined group of patients.

[Extracorporeal detoxication in patients with destructive pancreatitis].

Criteria of severity of endogenous intoxication in patients with destructive pancreatitis in enzymatic toxemia are discussed. It is demonstrated that the level of middle mass molecules and integral index of affection of the pancreas, abdominal cavity and retroperitoneal space are objective criteria of endogenous intoxication and can be used for determination of indications for extracorporeal detoxication and for assessment of treatment efficacy. Prescription of extracorporeal detoxication according to these criteria in an early period of the disease before multiple organ failure development promotes faster management of endotoxemia, prophylaxis of septic complications, decreases lethality and period of treatment of patients with destructive pancreatitis.

[Individual prognosis of severity of postoperative period and outcome of general peritonitis].

Evaluation of severity according to SAPS scale and examination of dynamics of middle molecules in blood plasma (MCMn) were carried out in 167 patients with different surgical diseases complicated with general peritonitis. It is demonstrated that level of MCMn compared with SAPS scale data is objective index of endotoxicosis, severity of general peritonitis, and it can be regarded as criterion of prognosis of disease outcome. Dynamic assessment of MCMn level has the most diagnostic importance in groups of patients with 5 - 12 scores according to SAPS scale. Prognostic value of this index is small when infectious-toxic shock occurs.

[Results of application of synthetic antioxidants in treatment of patients with destructive pancreatitis].

Results of examination and treatment of 103 patients with pancreonecrosis are presented. Influence of antioxidant mexidol on acute pancreatitis (AP) was studied. It is demonstrated that mexidol in AP permits to slow down destructive processes in the pancreas, promotes localization of inflammation and normalization of clinical and laboratory picture of the disease that permits to decrease significantly number of severe complications of AP and reduce lethality.

[Correction of enteral insufficiency syndrome in general peritonitis]. / Korrektsiia poiavlenii sindroma énteral'noi nedostatochnosti pri rasprostranennom peritonite.

Efficacy of enteral ozone lavage in combined treatment of patients with general peritonitis is analyzed. It is demonstrated that intestinal lavage with ozone-enriched physiological salt solution through nasointestinal probe in postoperative period eliminates effectively bacterial contamination of the intestine, decreases toxicity of enteral contents and leads to significant improvement of functional characteristics of the small intestine and results of treatment.

Cytological analysis of choledochal mucosa in acute cholangitis in patients with mechanical jaundice.

Changes in bile ducts in cholestasis are characterized by activation of proliferation and hypertrophy of cholangiocytes and degenerative and necrobiotic changes in ductal epithelium. Long-term cholestasis led to massive necrosis of cholangiocytes. Inflammatory changes in the choledochal mucosa were most pronounced in patients with choledocholithiasis.

[Sanative postoperative laparoscopy using rapid bacteriological methods in comprehensive treatment of patients with diffuse peritonitis]. / Sanatsionnaia posleoperatsionnaia laparoskopiia s bakteriologicheskim ékspress-metodom v kompleksnom lechenii bol'nykh s rasprostranennym peritonitom.

In treatment of patients with diffuse peritonitis the authors have been using postoperative sanative laparoscopy which proved to provide a means not only for rapid evaluating the dynamics of peritonitis course, but also for carrying out a series of therapeutic manipulations aimed at proper management of infections and inflammatory complications. Sanative laparoscopy was accompanied by taking samples of peritoneal exudate to study sensitivity of microflora to antibiotics and antiseptic substances, ensuring rational antibacterial treatment of peritonitis. This therapeutic method was used in 38 patients who underwent 60 examinations. Sanative laparoscopy was of a planned character in 30 patients, and in 8 cases it was carried out for emergency indications. All the studies were performed within 12-23 hours. A single examination was carried on in 11 subjects, the rest of the patients demanding from 2 to 3 examinations. No complications related to sanative laparoscopy were observed. Positive outcome was noted in the majority of the patients, re-laparoscopy being indicated but for 3 patients. Two patients died due to causes not related to the pathology involved.

[A method of determining the sensitivity of urinary microflora to antibacterial drugs]. / Metod opredeleniia chuvstvitel'nosti mikroflory mochi k antibakterial'nym preparatam.

A method has been developed for speedy determination of urinary microflora sensitivity to antibacterial drugs, which differs from other existing techniques by its simplicity and rapid realization. It is based on the capacity of micro-organisms as an aggregate of particles with a refraction coefficient, different from that of the environment, to increase its optic density by multiplication in a liquid nutrient medium in conditions of unlimited nutrition and space. Thus, increased optic density of a urinary specimen with an added antibacterial agent during incubation in a thermostat would indicate an increased count of micro-organism in the medium, i.e. the lack of sensitivity to the antibiotic in question. Optic density being unchanged under such conditions is evidence of the death (lack of growth) of the micro-organism population and, hence, its sensitivity to the anti-bacterial drug being assessed. The ultimate results being obtainable within 2 to 6 hrs and little effort involved are the advantages of this method over conventional techniques of the determination of urinary flora sensitivity to antibacterial drugs that are in current clinical use. Besides, adequate antibacterial treatment can already be initiated within the first day of admission where this test is used.

[A rapid test of urine microflora sensitivity to antibacterial drugs in the treatment of children with nonspecific inflammatory diseases of the kidney and urinary tract]. / Uskorennoe opredelenie chuvstvitel'nosti mikroflory mochi k antibakterial'nym preparatam v lechenii detei s nespetsificheskimi vospalitel'nymi zabolevaniiami pochek i mochevyvodiashchikh putei.

The authors describe their own method for rapid determination of urine microflora sensitivity to antibacterial drugs. The method is based on the capacity of the microorganisms (as a totality of particles with the refractive index different from that of the medium) of increasing the optical density of the medium under the conditions of unlimited resources of the nutrition and space at the expense of reproduction in a liquid culture medium. The lack of the optical density increase in the urine sample after addition to it of a certain amount of antibacterial substances evidences the death of the population of the microorganisms and of its sensitivity to the antibacterial drug under study. The method proposed by the authors was compared to those widely used in clinical practice. With special reference to a concrete patient, the results obtained with the authors' method turned out to correlate with those derived with the use of the conventional methods for urine microflora sensitivity to antibacterial drugs (the disc method and the triphenyltetrazolium chloride test). That the final result of the investigation can be obtained after 2--6 hours and low labour intensivity of the method permit the institution of adequate antibiotic therapy within the first day since the patient's admission to the hospital.