STRENGTHENING INFRASTRUCTURE FOR STRENGTHENING THE HEALTHCARE / Шинэ санаа Шинэ нээлт

Монгол улсад хоёрдогч буюу өмнө нь өөр улсад ашиглагдаж байсан, мөн олон жил ашигласан эмнэлгийн тоног төхөөрөмжүүд одоог хүртэл хэрэглэгдсээр байна. ЭМСЯ-ны төсөл хөтөлбөрүүд, Азийн Хөгжлийн Банк, ДЭМБ-ын Монгол дахь яаралтай үеийн тусламж үйлчилгээ, эмнэлгийн эрүүл ахуйн төсөл зэрэг нь орчин үеийн эрүүл мэндийн технологийг нэвтрүүлэх, эрүүл мэндийн салбарт тулгамдаж буй асуудлуудыгшийдвэрлэхийг зорьж байгаа билээ. Гэсэн хэдий ч орчин үеийн тоног төхөөрөмжүүдийг тухайлбал компьютерт томографи, соронзон резонанст томографийг ашиглах туршлагадутуу байх, үйл ажиллагааны горимыг зөрчих, тоног төхөөрөмжийн эвдрэл гэмтлүүд Улаанбаатар хот, аймгуудад түгээмэл байна. Эмнэлгийн тоног төхөөрөмжийн 20 жилийн хөгжлийн чиг хандлагаас харахад орчны болон дэд бүтцийн өөрчлөлтөнд тэсвэртэй программ хангамжтай,туйлын мэдрэг чанар өндөртэй, амархан гэмтдэг эд анги, бүрэлдэхүүн хэсгээс тогтсон эмнэлгийн тоног төхөөрөмжүүд ихээхэн ашиглагдаж байна. Эмнэлгийн технологийн гэмтлийг илрүүлж чадахгүй байх, ашиглалтын горимын шаардлагыг хангаж ажиллахгүй байх зэрэг нь орчин үеийн эмнэлгийн тоног төхөөрмжийн хөрөнгө оруулалт нь мөнгө хөрөнгө дэмий үрэгдсэн ажил болгон хувиргаж байна. Цахилгаан хангамж, усны шугамын найдвартай хэмжилт нь эмнэлгийн тоног төхөөрөмжийн найдвартай, аюулгүй ажиллагаа, чанарыг дээшлүүлэх болон дэд бүтцийг тогтворжуулах гол хүчин зүйл юм. Өндөр хүчдэл, гүйдлээс шалтгаалсан тоног төхөөрөмжийн гэмтлээс гадна үйл ажиллагаа, аюулгүй байдлаас хамаарсангэмтлүүдийг засварлах асуудал тулгарч байна. Чанарын болон эрсдэлийн удирдлага нь тоног төхөөрөмжийн үйл ажиллагаа, тохиргоог хангах учир эрүүл мэндийн үйлчилгээг бэхжүүлж чадна.

[Extracorporeal shock waves induce ventral-periosteal new bone formation out of the focus zone--results of an in-vivo animal trial]. / Extrakorporale Stosswellen induzieren ventral-periostale Knochenneubildung ausserhalb der Fokuszone - Ergebnisse einer In-vivo-Untersuchung am Tiermodell.

AIM: It is known that high-energy extracorporeal shock waves, focussed to the intact distal rabbit femur, induce periosteal new bone formation within the focus zone. This study was done to investigate whether there is additionally new bone formation outside of the focus zone, i. e., in the proximal femur, 10 days after shock wave application to the distal rabbit femur. METHOD: 18 adult Chinchilla-Bastard rabbits were randomly divided into three groups (A, B, C; each n = 6). One distal femur of each animal was focussed for shock wave application with different positive energy flux densities (A 1.2 mJ/mm (2), B 0.9 mJ/mm (2), C sham treatment). Only the proximal femur outside the shock wave focus was investigated. Here periosteal new bone formation was evaluated by fluorescent labelling. The maximum thickness was measured by means of computer-assisted image analysis. RESULTS: Maximum ventral-periosteal new bone formation outside the shock wave focus was significantly increased in group A compared to group B (p = 0.007) or group C (p = 0.001). In contrast, the maximum ventral-periosteal new bone formation outside the shock wave focus demonstrated no statistically significant difference in group B compared to group C (p = 1.0). CONCLUSION: Depending from the amount of positive energy flux density applied to distal rabbit femur a significantly increased ventral-periosteal new bone formation results in the proximal rabbit femur outside the shock wave focus.

Impaired tensile strength after shock-wave application in an animal model of tendon calcification.

Extracorporeal shock-wave application facilitates dissolution of rotator cuff calcifications. Therefore, disappearance or disintegration of tendon calcifications by shock waves might be appropriate for any kind of tendon calcification. Here, shock waves with various energy flux densities were applied to the mineralized medial gastrocnemius tendon of turkeys as an animal model. After application of shock waves in vivo, with energy flux density of 0.6 mJ/mm(2), histologic examination and microradiography did not show dissolution or disintegration of tendon calcifications. After shock-wave application in vitro, even for energy flux density of 1.2 mJ/mm(2) neither dissolution nor disintegration of tendon calcifications were observed. Biomechanical testing revealed significant impairment of tensile strength following shock-wave application in vitro, with energy flux density of 1.2 mJ/mm(2), but not with 0.6 mJ/mm(2). These results are important for considerations of clinical extracorporeal shock-wave application on tendon calcifications, as well as on tendon ossifications.

[Physical parameters of extracorporeal shock waves]. / Physikalische Parameter extrakorporaler Stosswellen.

Prerequisites for the successful investigation of the mechanism of action of ESWT (extracorporeal shockwave therapy) and the establishment of treatment standards, are the ability to measure, and a knowledge of, the physical parameters involved. The most accurate measurements are obtained with laser hydrophones. Various parameters (amplitude, rise time, pulse width, pressure pulse decay, rarification phase) of a typical shock wave can thus be determined. These can then be used to calculate energy flux density, focal extent, focal volume and as well as focal energy, effective energy in a defined area, and effective biological energy. These parameters can be utilized to work out a theoretical treatment protocol.

Extracorporeal shock waves act by shock wave-gas bubble interaction.

The effect of extracorporeal shock waves on hemoglobin release from red blood cells was recently found to be minimized under minute static excess pressure. It was proposed that this can be explained by shock wave-gas bubble interaction. We substantiated this further by two experiments by applying shock waves to suspended human RBC in a lithotripter at a lower frequency (1 pulse every 5 s) and by administering just a single or 2 strong shock waves at 30 kV. Compared to the usual application rate of 1 discharge per s, the lower frequency reduced the hemoglobin release under minimal static excess pressure in the range from 0-100 kPa. A single strong shock wave released a small amount of hemoglobin at ambient pressure and a similar amount at 200 kPa excess pressure. Two strong shock waves increased the hemoglobin release considerably at ambient pressure when there was a 1- or a 10-s pause between them. Under 200 kPa excess pressure, the hemoglobin release was minimal. A similar low hemoglobin release was also found with 1 shock at ambient and the other at excess pressure. The results are interpreted as clear evidence of shock wave-gas bubble interaction as a dominant mechanism of shock wave action.

Acoustic energy determines haemoglobin release from erythrocytes by extracorporeal shock waves in vitro.

Haemoglobin release from erythrocytes by extracorporeal shock waves from an electrohydraulic lithotripter was quantified and correlated with the acoustic energy administered to the cell container. Cells were exposed in 2-, 5.9-, and 10.5-mL vials to 100 shock waves delivered at a low, medium and high lithotripter output setting, both with and without covering of the central ellipsoidal axis by a metal cage. Using the identical set-up, previous experiments had shown that the fragmentation efficiency was linearly correlated with the delivered acoustic energy. As a result, shock waves generated from 0.83 microgram mJ-1 (in 2-mL vials) to 1.53 micrograms mJ-1 (in 10.5-mL vials) haemoglobin. At all vial types, the amount of haemoglobin correlated linearly with the delivered acoustic energy (r = 0.96 in 2-mL, r = 0.97 in 5.9-mL and r = 0.98 in 10.5-mL vials). It was independent of the presence of the cage.

Destruction of gallstones and model stones by extracorporeal shock waves.

The disintegration effectivity of an electrohydraulic lithotripter was evaluated by determining the acoustic energy that had to be applied, until all fragments of three artificial materials and human gallstones were cleared from a basket of 2.8 mm mesh size. The lithotripter had either an open ellipsoid, or the ellipsoidal axis was covered with a metal cage as used in clinical lithotripters to house the ultrasound scanner. Fragmentation was assessed at a low, medium and high voltage setting using 9 and 16 mm breeze block marbles, considered to be primarily fragmented by a cavitation-mediated mechanism; 16 mm glass marbles, considered to be primarily fragmented by a direct shock wave effect; 12 and 15 mm plaster balls as commonly used to monitor lithotripter output; and gallstones with a mean diameter of 16 mm. As a result, the acoustic energy for the disintegration of 9 and 16 mm breeze block marbles was 620 and 670 mJ cm-3, of glass marbles 3369 mJ cm-3, of 12 and 15 mm plaster balls 1599 and 1764 mJ cm-3 and of gallstones 8050 mJ cm-3. It was largely independent of pulse energy, specimen size and configuration of the shock wave source. It is concluded that acoustic energy is a major determinant of disintegration, independent of the presumed mechanism of destruction.

[Disintegration of kidney calculi by piezoelectrically generated high-energy sound waves. Physical principles and experimental studies]. / Die Zertrümmerung von Nierensteinen durch piezoelektrisch erzeugte Hochenergie-Schallpulse. Physikalische Grundlagen und experimentelle Untersuchungen.

The recently developed equipment for extracorporeal piezoelectric lithotripsy (EPL) represents an improvement concerning the shock-wave-induced disintegration of urinary calculi. While the usual spark gap transmitter needs a focusing reflector, the piezoelectric lithotriptor is based on a self-focusing spherical bowl transmitter. The stone is detected exclusively by ultrasound. For this purpose, an integrated sector scanner is used as well as the high-energy sound transmitter itself. With the piezoelectrically generated high-energy sound pulses we have succeeded in completely disintegrating implanted stones in the renal pelvis of dogs without injuring the morphology or function of the exposed kidneys.

[Disintegration of kidney calculi with a piezoelectric instrument system. Initial clinical experiences]. / Die Zertrümmerung von Nierensteinen mit einem piezoelektrischen Gerätesystem. Erste klinische Erfahrungen.

Since December 1985 extracorporeal piezoelectric renal lithotripsy has been tested in humans. Up to now 50 patients with renal calculi have been treated. The lithotriptor consists of a special mobile table with an opening in the surface to apply shock waves. Urinary calculi are located by integrated ultrasound location systems. As the piezoelectrically generated high-energy sound pulse does not cause pain, treatment is possible without anesthesia. Permanent ultrasonic control of the stones in the focus during lithotripsy allows effective application of shock waves. With this piezoelectric system the electrocardiogram does not have to be triggered. So far the results have been encouraging and following these tests clinical application is expected to be successful.