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25скорой помощи с жалобами на мелькание «мушек» перед глазами, головную боль, боли в левом подреберье, с иррадиацией в поясничную область, колющие и резкие боли в правом подреберье с иррадиацией в эпигастральную область, поднялась температура до 38. Врачом скорой помощи был поставлен предварительный диагноз - острый панкреатит (измерено АД 220/120), введена магнезия, больная госпитализирована в хирургическое отделение БУЗ УР 1 РКБ. На основании:
- жалоб на головную боль, мелькание «мушек» перед глазами, слабость, горечь во рту, тошноту, боли в правом и левом подреберье, эпигастральной области, носящие резкий, колющий характер, многократную рвоту с примесью желчи.
- anamnesis morbi - Пациентка считает себя больной с 30.03.2017, когда впервые появились жалобы на тошноту, колющие боли в правом подреберье. В дальнейшем отмечала нарастание болевого синдрома, появилось ощущение горечи во рту, рвота.
- данных объективного обследования - язык обложен желтоватым налетом, живот резко болезненный при пальпации в правом подреберье, симптомы Кера, Ортнера положительные. Печень увеличена, нижний край выступает из-под края реберной дуги на 1,0 см., болезненна.
Ставится предварительный диагноз - острый холецистит.
Список литературы
1. Хирургические болезни, 2-е издание. М.И. Кузин - ред. М. Медицина, 1995 г.
2. Лекции по хирургическим болезням. «Спаечная болезнь». С.В. Рачинский.
3. Алиев М.А., Шальков Ю.Л. Хирургия острой кишечной непроходимости // Алматы: «Б1Л1М», 1996. 256 с.
COMPREHENSIVE APPROACH TO THE PROBLEM
OF REHABILITATION OF INFANTS SUBMITTED SEPSIS
1 2 Shamsiyev A.M. , Rabbimova D.T.
1Shamsiyev Azamat Mukhitdinovich - Rector, Professor, DEPARTMENT OF PEDIATRIC SURGERY;
2Rabbimova Dilfuza Tashtemirovna - Associate Professor, Head of the Department, DEPARTMENT OF PROPAEDEUTIC OF CHILDREN'S DISEASES, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: a comparative study in two groups of children who received a complex of restorative therapy in the rehabilitation period, with measures to correct the intestinal biocenosis, neurometabolic therapy and immunotherapy with Viferon and children receiving only the Taktivin immunomodulator showed a significant effectiveness of the integrated approach in rehabilitation. In addition, the comparatively fast positive immunological effect achieved, the good tolerability of the drug Viferon, the non-invasive route of administration, and the absence of adverse reactions with the described immunorehabilitation technique, make it possible to recommend this drug to a complex of immunorehabilitation measures in infants who have undergone sepsis. Keywords: sepsis, children, rehabilitation.
UDC: 616.94-022.7
Introduction. Violation of the functions of vital organs against the background of a general homeostasis disorder in infants who have suffered sepsis creates a risk of protracted or recurrent course, in addition, the transferred bacterial stress is reflected in the further growth and development of the child [2, 5, 9, 10]. There is every reason to believe that in patients who have recovered at an early age, a secondary immunological failure or prolongation of the formation of immunity is formed [3, 6, 8]. All this dictates the need for mandatory rehabilitation activities for these children [1, 4, 7]. In this regard, the purpose of our study was to evaluate the effectiveness of complex rehabilitation measures in infants with sepsis in the process of follow-up.
Material and methods of investigation. Follow-up care included 60 children aged 1 month to 1 year who received treatment for sepsis at the Children's Surgery Branch of Samarkand in the branch of the National Children's Hospital of the Republic of Moldova (Director - Prof. A. Shamsiev). In the follow-up survey, indicators of physical, psychomotor development, the state of functioning of organs and systems were taken into account, the immune status was assessed according to the following indices: -assessment of cellular immunity by the number of circulating T-lymphocytes (CD3) and their subpopulations: T-helpers (CD4), cytotoxic T-l suppressors (CD8), immunoregulatory index (IRI), ie CD4 / CD8 ratio;
- evaluation of the humoral immunity level by the content of B-lymphocytes (CD22) and the content of serum immunoglobulins of classes A, M, G. The activity of neutrophilic granulocytes was evaluated in phagocytosis reactions to determine the degree of its completeness: the percentage of phagotytic neutrophils, the number of absorbed microbes (average per cell), and the index of phagocytosis completeness were counted. According to cardiointervalography (CIG), the vegetative maintenance of adaptive-adaptive reactions was evaluated in patients with sepsis
Surveys at the stage of rehabilitation were carried out every 3 months, for 12 months, as necessary and more often. All children were counseled by a pediatric neurologist. The results of the studies were statistically processed. Reliability was determined from the tables of Fisher-Student.
The results of the study and their discussion. It should be noted that children with sepsis had various abnormalities in physical and psychomotor development, as well as in the functional state of organs. Almost everyone noted violations in the formation of motor functions. In 75% of patients, mild hepatomegaly was noted, and changes in the cardiovascular system were determined in 56.6%. All (100%) children had mild to moderate iron deficiency anemia. In 88.3% of children persistent violations from the gastrointestinal tract, associated with the development of acquired fermentopathy, manifestations of intestinal dysbiosis of 1-2 degrees persisted. Deviations from the immune system in the form of a decrease in the helper activity of T-lymphocytes, dissymunoglobulinemia, as well as changes in nonspecific immunity in the form of a decrease in the phagocytosis index, were the reason for immunorehabilitation in infants who had sepsis. Evaluation of the autonomic tone of children according to cardiointervalography testified that hypersympathicotonia persisted in 26.6% of children, sympathicotonia in 56.7%, 10% had vagotonia, and 6.7% had eutonium.
The stress index varied from 1589 conventional units. up to 2,000 units, i.e., characterized the remaining tension of adaptation processes in children with sepsis and may be a criterion for the repeated disruption of adaptation mechanisms that promote the relapse of sepsis in these children.
Such deviations in the functioning of the sympathetic-adrenal system, which determine the formation of vegetative-visceral disorders of neuroendocrine regulation of adaptation processes, are the rationale for the inclusion of treatment-rehabilitation measures in infants with sepsis-mediated nootropic drugs, physiologically regulated mechanisms affecting the neurotransmitter systems of the brain, metabolic and bioenergetic processes in the nerve tissue.
Considering the above changes, the complex of restorative therapy for sepsis in infants included the following main directions:
1. Correction of intestinal biocenosis
a) use of prebiotics, if necessary, antimycotic therapy,
b) providing breastfeeding, and in the absence of breast milk, the use of adapted mixtures enriched with bifidobacteria (Nutrilon, NAN fermented milk)
2. Immunorehabilitation;
3. Neurometabolic therapy.
In order to correct the dysbiotic disorders, the prebiotic Hilak forte was applied 20 drops x 3 times a day, and the probiotic-Linex-one capsule of which contains at least 1.2 x 107 living bacteria. In its composition, in addition to lacto- and bifidobacteria, there are strains of lactobacillus streptococcus: Lactobacillus acidophilus, Bifidobacterium infantis v. liberorum and Streptococcus faecium SF68. The drug was used according to the scheme of 1 capsule 2 times a day.
For the purpose of neurometabolite therapy, piracetam and glutamic acid were used at the age-related dosage.
For the purpose of immunocorrection, human recombinant interferon a-Viferon was used in infants after the sepsis was transferred. Viferon was used in a dose of 150 thousand units of ED 2 times a day with the administration of suppositories 3 times a week for 3 months in the period of clinical well-being. The advantage of Viferon is a non-invasive method of administration, long-term use of Viferon does not have adverse reactions in patients.
Children were divided into 2 groups: 1 group received comprehensive rehabilitation therapy 2 group received only immunocorrective therapy with Tactinol in the form of 0.01% solution for injection, which is administered at a dose of 25 mg / kg subcutaneously once a day for 10 days.
The results of the study of the immune status and phagocytosis in the study children of Groups 1 and 2.
After 3 months in children of group 1, the condition of patients of both groups remained stably satisfactory. Weight gain was positive in 51.4% of patients in group 1, in group 2, a sufficient weight gain was characteristic of 36% of patients. Intestinal dysfunctions were not observed in 74.3% of children from group 1, and of group 2 in 25% of children. In 17.1% of the children of group 1, psychomotor development was already consistent with age, in the second group only 8% of the observed dynamics were observed.
Immunological indicators still differed from normal values, although in the 1 group in terms of such indicators as CD4 +, IgA, the index of phagocytosis, there was a tendency to increase. The tolerability of viferon was satisfactory, there were no adverse reactions.
Six months after the start of the rehabilitation course, the condition and health of the children of group 1 were consistently satisfactory, there were no clinical signs of inflammation.72,7% of children caught up with their peers by weight, psychomotor development corresponded to the age of 30.3% of children. 84,8% had no intestinal dysfunction. The recurrence of the septic process and acute respiratory infections during this period of time in this group of subjects was not observed in any child. In terms of T-helpers, the ratio of CD4 + / CD8 +, immunoglobulins A, G significantly increased in comparison with baseline values at the beginning of the recovery period and reached the normal values by this rehabilitation period.
In the 2nd group within 6 months 43.4% of children had episodes of body temperature rise to subfibril digits combined with catarrhal symptoms from the upper respiratory system, which was regarded as manifestations of intercurrent acute respiratory infection. The duration of respiratory disease was 10-12 days. Dysfunction from the gastrointestinal tract was noted in 52.3%. Positive weight gain was in 39% of patients. By this time, psychomotor development corresponded to the norm in 17.4% of children in group 2.
The same dynamics of clinical indices was also characteristic after 9 months of observation: positive dynamics in the body mass curve in group 1 was in 80%, and at 12 months in 88.6%, the development of children from the side of psychomotor activity in 57.1% - for 9 months and 77.4% for 12 months of observation. Episodes of intestinal
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dysfunction were observed in 11.4% for 9 months and 5.7% for 12 months of rehabilitation activities. In this group, there were no cases of recurrence of the septic process and acute respiratory infection, while of the 2 groups in 12 months, 17.6% of the children were re-hospitalized, and all children transferred acute respiratory-viral infections, at times repeatedly. In 36% of 9 months of follow-up and 41.6% in 12 months there were phenomena of intestinal dysfunction. Only 24% and 29% of 9 months and 12 months of follow-up corresponded to normal psychomotor development.
Immune status in the children studied during the period of 3, 6, 9 and 12 months of observation was more quickly restored among the children of group 1: by 6 months, normalization was observed in many immunity parameters: the values of helper T-lymphocytes reached the norm, and in 2 children this index increased significantly Only after 9 months and reached the norm - in 12 months. The same dynamics of changes was observed in IgA, IgG, index of phagocytosis. T suppressors remained significantly high for 6 months in both compared groups, then 9 months later in 1 group of children normalized, and in 2 groups of children remained high and by 12 months of follow-up.
This was reflected in the CD4 + / CD8 + index, which was significantly higher in the 1st group than the beginning of the recovery period at 6 months, and at 9 months it was normal. In the 2nd group, this indicator returned to the 12th month of follow-up. In addition, when assessing the frequency of distribution of different types of initial vegetative tone in the structure of providing the organism to children with sepsis, differences were found depending on the method of rehabilitation. Thus, in children of group 1 and 2 groups, the onset of the recovery period was characterized by a high activity of the sympathetic link in the regulation of the autonomic nervous system with an increase in the frequency of hypersympathicotonia compared with healthy children. In the following stages, there was a dynamic decrease in the frequency of hypersympathicotonia and sympathicotonia in the 1 group of children studied. At the same time there was an increase in children with eutony. It follows that the applied complex approach to the rehabilitation of children with sepsis from the point of view of the evaluation of the reactivity of the organism indicates a decrease in the tension of the adaptation mechanisms, and in the process of maintaining homeostasis, higher levels of management are not included, indicating a certain degree of maintenance of the state of satisfactory adaptation in children of group 1.
The initial level of GIH indices in the recovery period in children of the 1st group was gradually approaching that of healthy children. There was a reorganization of the interrelations of the sympathetic and parasympathetic parts of the nervous system along the path of strengthening the latter. This manifested itself in an increase in the indices of CIG, such as Mo, Дх, and a decrease in AMO.
Thus, a comparative study in two groups of children who received a complex of restorative therapy in the rehabilitation period, with measures to correct the intestinal biocenosis, neurometabolic therapy and immunotherapy with Viferon and children receiving only the Taktivin immunomodulator showed a significant effectiveness of the integrated approach in rehabilitation. In addition, the comparatively fast positive immunological effect achieved, the good tolerability of the drug Viferon, the non-invasive route of administration, and the absence of adverse reactions with the described immunorehabilitation technique, make it possible to recommend this drug to a complex of immunorehabilitation measures in infants who have undergone sepsis.
References
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A DIFFERENTIATED APPROACH IN THE SURGERY OF LIVER ECHINOCOCCOSIS
12 3
Shamsiyev A.M. , Shamsiyev J.A. , Kurbaniyazov Z.B. , Rakhmanov K.E.4, Davlatov S.S.5
1Shamsiyev Azamat Muxitdinovich - Professor, DEPARTMENT OF PEDIATRIC SURGERY; 2Shamsiyev Jamshid Azamatovich - Professor, Head of the Department, DEPARTMENT OF PEDIATRIC SURGERY POSTGRADUATE, MEDICAL FACULTY; 3Kurbaniyazov Zafar Babajanovich - PhD, Associate Professor, Head of the Department; 4Rakhmanov Kosim Erdanovich - Competitor Research; 5Davlatov Salim Sulaymonovich - Senior Teacher, DEPARTMENT OF SURGICAL DISEASES № 1, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: the work is based on the experience of surgical treatment of 427 patients with echinococcosis of the liver of various locations operated in the 2nd clinic of SamSMI from 2003 to 2015. In the years 2003-2006. We operated 154 (36.1%) patients. These patients made up a control group. The comparison group included 134 (31.4%) patients operated in 20072010. The main group included 139 (32.5%) patients operated in 2011-2015. In comparison with 2003-2006. The incidence of postoperative complications decreased almost 5-fold - from 18.4% to 4.0%. Relapses of echinococcosis in the long term after surgery appeared in 12.9% of patients, and in the group of persons operated in 2003-2006, this indicator reached 28.2%. In subsequent years, against the background of intra- and postoperative prophylaxis of the disease, the number of relapses in the comparison group was reduced to 8.8%, and in the main group was reduced to zero. Among the main germicides, 80-100% glycerol, heated to 70 °C, does not cause destructive changes in the adjacent parenchyma, the brightest and quickest scolexic effect. In the surgery of liver echinococcosis, preference should be given to the topical mini-access, the possibilities of which can be significantly expanded by intraoperative ultrasound and video endoscopic assisting.
Keywords: liver echinococcosis, surgical treatment, relapse prevention.
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