[Use of thrombolytic therapy and rheolytic thrombectomy in treatment of pulmonary artery thromboembolism].

The article deals with the results of combined treatment of patients with pulmonary thromboembolism by means of systemic thrombolytic therapy, anticoagulant therapy, and rheolytic thrombectomy during the period from 2012 to 2013. Thrombolytic therapy was used in 78 of 187 patients with the confirmed diagnosis of pulmonary thromboembolism (Group 1). The diagnosis was verified and therapeutic results were controlled by means of contrast-enhanced spiral computed tomography and perfusion scintigraphy. Thrombolysis was carried out using: tissue plasminogen activator - alteplase (61 cases) with administration of the full dose during 2 hours, streptokinase (14 cases) at a dose of 1.5 million IU in the mode of prolonged infusion during 24 hours and urokinase (3 cases) at a dose of 4400 IU/kg during 12 hours. 109 patients were subjected to anticoagulant therapy (Group 2). Five patients were subjected to rheolytic thrombectomy for desobstruction of the pulmonary artery. The method was used in patients with previously performed ineffective or partially effective thrombolytic therapy, as well as in patients with contraindications to thrombolysis. The lethality rate for TLT amounted to 5.4% and that for anticoagulant therapy 26.6%. Probability of a lethal outcome in Group 2 (anticoagulant therapy) turned out to be 6.71 times higher as compared with Group 1 (thrombolytic therapy). In all cases of using rheolytic thrombectomy we managed to achieve a decrease of the Miller index and systolic pressure in the pulmonary artery. Desobstruction of the pulmonary artery was complete in 3 cases. In two cases rheolytic thrombectomy was partially effective and the patients underwent repeat thrombolysis with a good clinical outcome. Using systemic thrombolysis in patients with pulmonary artery thromboembolism demonstrated a positive effect on the prognosis of survival. Rheolytic thrombectomy contributed to improvement of the results of thrombolytic therapy and may be used as an alternative method of treatment.

[Mini-invasive technologies in treatment of acute cholecystitis in patients with high operational and anesthetic risk].

The treatment results of 769 patients with acute calculous cholecystitis and high operational and anesthetic risk at admission are presented in the retrospective study. High risk was determined by expressed comorbidities, diseases' terms, the complications of acute cholecystitis, age, which was more than 60 years in most cases. The patients were divided into 2 groups depending on the severity of comorbidity and the possible effects of its correction. The first group included 617 perspective patients for cholecystectomy. And the second group included 152 patients unpromising for this. Concept of stage treatment was used in the first group including primary decompression of the gallbladder by using of percutaneous transhepatic micro-cholecystostomy under ultrasound guidance. Cholecystectomy was performed after correction of comorbidities, complications of acute cholecystitis, and readjustment of extrahepatic bile ducts by endoscopy if necessary. Laparoscopic cholecystectomy was successfully performed in 587 patients. There was open cholecystectomy in 11 cases. Cholecystectomy was done in 19 patients as a result of conversion. Cholecystostomy from minimal access with extraction of stones under local anesthesia was performed in the second group for decompression and as definitive treatment. There was not observed deaths in patients with high operational and anesthetic risk as a result of such tactics. Postoperatively 1.7% of patients had complications that were successfully resolved.

[Structure of nocturnal sleep if there is a violation of the blood supply in the territory of internal carotid artery].

The work examines the influence of degree ofstenosis or occlusion of the internal carotid artery (ICA) of noc- turnal sleep and discusses possible neurophysiological mechanisms of sleep disorders when blood flow in ca- rotid system. 24 patients (19 male and 5 female) were examined. The mean age of men was 49.75 ± 6.55; women--46.67 ± 5.86. Six patients with a single unilateral internal carotid stenosis (ICA) 50%; seven patients--stenosis of ICA 50-70%; eleven patients--occlusion of ICA completed the study. Polysomnography was recorded with "Neuro-Spectr-5/EP" ("NeuroSoft", Russia) and "Delta Flash" ("Deltamed", France) according to international recommendation. Stages of sleep were identified according to Re- chtschaffen A., Kales A. (1968) criteria. Patients were asked to fill in the questionnaire prior to clinical and polysomnographic evaluation. Regional cerebral blood flow (mL/100g/min) with 99mTechnetium (Gamma-camera, DST-Xli "General electric", USA) was study by single photon emission CT imaging. The result of this study showed that with stenosis of the ICA to 50% structure of nocturnal sleep is not changed: records all phases and stages of sleep, quantitative parameters that match the normative data; or decline in the representation of only the stage II sleep; at stenosis ICA of 50-70% is violation of mostly stage II sleep and slow-wave sleep, and with occlusion ICA violation slow-wave sleep and in 45% of cases--REM-sleep.

[Assessment of the diagnostic value of perfusion scintigraphy in diagnosis of pulmonary artery thromboembolism].

The present work was aimed at specifying the place of perfusion scintigraphy of the lungs in the diagnostic algorithm of pulmonary artery thromboembolism (PATE) and at determining sensitivity, specificity, and accuracy of the method concerned. The authors analysed the data regarding a total of 211 patients divided into two groups (Group One with an arbitrary algorithm of investigation, comprising 108 patients and Group Two with the suggested algorithm of «pulmonary roentgenography Doppler ultrasonography perfusion scintigraphy of the lungs¼) in clinically suspected pulmonary artery thromboembolism and scintigraphy-revealed defects of perfusion. The diagnostic complex included ECG, Doppler ultrasonography of the veins, roentgenography, perfusion scintigraphy of the lungs, and in a series of doubtful cases Echo-CG and CT angiography of the lungs. We revealed reliable signs of pulmonary artery thromboembolism (PATE) by the findings of instrumental diagnostic methods, having demonstrated a considerable increase in specificity and accuracy of perfusion scintigraphy in diagnosing PATE using the proposed diagnostic algorithm, when scintigraphy stands on the third position (specificity increased by 78% and accuracy by 22%). The following recommendations were made: the findings of scintigraphy should be interpreted with due regard for the data of roentgenography and Doppler ultrasonography of the veins; if the patient s condition is severe, the examination may be limited to roentgenography alone prior to performing perfusion scintigraphy of the lungs.

[Diagnostics and treatment of posttraumatic septic costal osteomyelitis].

Results of treatment and diagnostics of 47 patients with posttraumatic septic costal osteomyelitis were analyzed. 26 patients had open and 21 - closed thoracic injuries. Major reasons of osteomyelitis tended to be the initial infection of the bony injury, pleural surgical revision through the initial wound and late medical help by the closed thoracic injuries. Osteomyelitis was diagnosed with the help of and X-ray examination in 14,9%, multispiral computed tomography was informative in 48,4% and scintigraphy demonstrated bone destruction and inflammation in 96,8% of cases. With no depandance from the type of an injury, the most frequent infectious agents were the Staphylococcus aureus (51,2%) and Pseudomonas aeruginosa (32,5%). Conservative treatment was successful in 26,9% after open injuries and in 42,9% of the blunt thoracic trauma. Wide costal resections were conducted in 73,1% and 52,4% of patients with open and closed injuries, respectively.

[Clinical and ultrasound diagnostics of acute venous thrombosis].

The results of clinical and ultrasound diagnostics of acute venous lower limbs thrombosis in 206 patients are analyzed. The patients were divided in two groups; those in the first group (n=96) had a diagnosed pulmonary embolism, patients of the second (n=110) had no signs of it. 37 (18%) patients had an asymptomatic course of venous thrombosis, 25 (68%) of those were diagnosed with pulmonary embolism. 154 (74%) patients had floating thrombs, which resulted in pulmonary embolism in 53%. Clinical and ultrasound criteria of embologenic venous trombosis are developed. It allows prognose the pulmonary embolism development and optimize the treatment tactics.

[Hepatobiliscintigraphy in the diagnosis of obstructive jaundice].

The authors show the role of hepatobiliscintigraphy (HBSG) in cholelithiasis as a screening technique in evaluating the patency of the common bile duct, which allows cholecystectomy to be performed if there are normal values, without resorting to additional studies. They have reprospectively analyzed the results of clinical and instrumental studies in 101 patients with cholelithiasis and obstructive jaundice of various etiology in whom the diagnosis was verified by endoscopic cholangiopancreatography (ERCPG). The sensitivity, specificity, and diagnostic efficiency of the scintigraphic technique were 96.5, 36.3, and 86.1%, respectively. It is recommended that invasive diagnostic techniques, such as ERCPG and other direst X-ray contrasting methods, should be used after having a positive result of two techniques: ultrasonography and HBSG (in the above order).

[Lung perfusion scanning in the comprehensive diagnosis of pulmonary thromboembolism].

The aim of the study was to define the sensitivity, specificity, and diagnostic accuracy of lung perfusion scanning (LPS) in pulmonary thromboembolism (PTE). PTE diagnostic techniques are comparatively assessed. The data on 108 patients with suspected PTE and lung perfusion defects revealed at pulmonary scintigraphy were analyzed. The diagnostic techniques included electrocardiography (ECG), 150 echocardiography, venous ultrasonography, chest X-ray, and LPS. The significant signs of PTE were singled out of 150 ones (history data, complaints, clinical symptoms, instrumental findings, autopsy data); LPS data were analyzed in detail. The sensitivity, specificity, and accuracy of LPS were 95.2, 20, and 77.7%, respectively. It is shown that lung scans should be interpreted, by taking into account X-ray data, and LPS should follow ECG, venous ultrasonography, and chest X-ray.

[Gastric and intestinal scintigraphy in the complex diagnosis of small bowel obstruction].

An algorithm has been developed for radiation diagnosis of small bowel obstruction, which involves abdominal X-ray and ultrasound studies at the first stage and radionuclide evaluation of gastrointestinal transit, by using 100-150 ml of aqueous 99mTc-technefite or 99mTc-bromeside solution in a dose of 50-100 MBq (radiation load 0.7-1.4 MeV) per os. The sensitivity, specificity, and diagnostic efficiency of the whole radiation diagnostic complex and each procedure separately were determined by the results of examination in 180 patients with suspected small bowel obstruction, of whom 104 patients were operated on, but obstruction ceased during medical treatment. Inclusion of the radionuclide technique into the diagnostic complex involving plain radiography and ultrasonography was shown to enhance diagnostic efficiency up to 97-98%.

[Gastroduodenal bleedings in critical illness]. / Gastroduodenal'nye krovotecheniia pri kriticheskikh sostoianiiakh.

Acute erosive lesions of upper parts of gastrointestinal tract with bleeding aggravate severe burn trauma, postoperative period after extensive surgeries and is the often component of polyorganic insufficiency syndrome. Gastric secretion in patients with severe burn trauma and neurotrauma was studied. Decrease of gastric secretory function due to central paresis of gastrointestinal tract and reflux of bile into stomach was seen in majority of patients with neurotrauma and acute gastric ulcers. On the contrary, in patients with burn shock increase of acid-secretory function of stomach was revealed. Schemes of prophylaxis and treatment of acute ulcers were developed. They included antacid therapy (for patients with increased secretion), regulators of motor-evacuatory function of stomach and intestine (for patients with paresis), drugs increased regenerative properties of mucosa, early enteral nutrition with balanced mixtures. This treatment in combination with hemostatic therapy and cure of main disease permitted to reduce number of gastroduodenal bleedings and lethality in these patients.

[Instrumental diagnosis of reflux esophagitis]. / Instrumental'naia diagnostika refliuks-ézofagita.

One hundred and forty patients with clinical symptoms of gastroesophageal reflux disease were examined. Instrumental examination included esophagogastroduodenoscopy (140 patients) with target biopsy (44 patients), x-ray study of the esophagus and stomach (95), intragastric pH-metry (74), esophagomanometry (67). It is demonstrated that all the patients with clinical picture of gastroesophageal reflux disease suffer from reflux-esophagitis (RE) of various severity. Definite morphological equivalents correspond to each of endoscopic forms of RE. Complex instrumental diagnosis of RE must include intragastric pH-metry and esophagomanometry in line with esophagogastroduodenoscopy and morphological study. It is necessary to perform x-ray study in peptic strictures of the esophagus and in combination of RE with large axial hiatal hernias. Cardial or cardial-fundal hiatal hernia, increase of intragastric pressure and hyperacidity promote development of the most severe (destructive) forms of RE.

[Treatment of acute ulcerations of the upper part of the gastrointestinal tract in patient with a neuroreanimation profile]. / Lechenie ostrykh iz''iazvlenii verkhnikh otdelov zheludochno-kishechnogo trakta u bol'nykh neiroreanimatsionnogo profilia.

A success in treatment of acute ulcerations of the upper parts of the gastrointestinal tract in patients with a severe neurosurgical pathology can be achieved only with a complex approach to treatment of the intensive care patients. The application of antiulcerous medicines in combination with pyrokinetics and medicines improving the regeneratory ability of the gastrointestinal tract mucosa allowed to considerably decrease risk of the development of gastroduodenal bleedings against the background of erosive-ulcerous lesion of the mucosa. The endoscopic methods of arresting bleedings in such patients in combination with the correction of homeostasis by infusions and local hemostatic therapy in most cases result in reliable hemostasis of the upper parts of the gastrointestinal tract. The program of active measures is completed with the early enteral feeding with balanced nutritional mixtures.

[Enteral infusion-nutritional correction of homeostasis in patients with postburn cicatricial stenosis of the esophagus and stomach]. / Enteral'naia infuzionno-nutritivnaia korrektsiia gomeostaza u bol'nykh s postozhogovymi rubtsovymi suzheniiami pischevoda i zheludka.

The metabolic status was studied in 67 patients with postburn cicatricial strictures of the esophagus (39) and of the pyloric part of the stomach (28). The aim of the work was to find the methods of enteral nutrition with special mixtures. The composition of the mixtures must be close to that of the chyme. In addition to changes of the standard parameters (pH, enzymatic and electrical activity) the assessment of the state of the digestive tract included the estimation and description of certain disorders in the system of heterophasic hydrolysis in the gastrojejunal tract (enzyme activity in fractions of the duodenal juice, enzyme sorption on the flocular structures) in the both categories of the patients. The authors recommend to treat such patients with the special mixtures "Nutrichim" or using the new corrector "Flokozim".