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The results of microbiological studies
Microbiological studies were carried out to identify the causative agent and determination of CFU, as well as to monitor the effectiveness of the treatment. Gathering pathologic releasing substance from the wound to the qualitative analysis of the microflora was performed using a sterile swab, which was placed in a special tube to transport the coal environment.
The sensitivity of the isolates to antibiotics was determined by the standard technique for disks. In addition, it was conducted quantitative research methods to determine the level of microbial contamination in 1 gram of tissue injury. It should be noted that this method is the most informative.
When determining overall characteristics of the selected agents, it was found, that they mainly represented by staphylococcus and gram-negative flora. The leading role in microbiological study of releasing substance from purulent wounds took St. Aureus (62.5 %); Proteus mirabilis (54.8 %); E. Colli (50.8 %) and a small amount Str. Pyogenus (12.5 %). It should be noted, that the above listed organisms are major pathogens of purulent infection in surgery.
When determining the sensitivity was defined that most of the identified bacteria showed resistance to the most widely used antibiotics and retained sensitivity to cephalosporin, aminoglycoside and fluoroquinolones antibiotics past generations. So, they were the most sensitive to ciprofloxacin, cefazolin and rifampicin and less sensitive to penicillin and erythromycin. Furthermore, they were multi-resistant to several antibiotics simultaneously. These results suggest that the microflora isolated from purulent wounds is often a multi-resistant. Therefore, at the beginning of the complex treatment of purulent wounds it is recommended to appoint ciprofloxacin and rifampicin, ceftriaxone, and after receiving the results of the study of bacterial purulent wounds, antibiotic therapy should be corrected taking into account the sensitivity of microorganisms to antibiotics.
Along with the quality of microbiological studies of quantitative methods of research have been conducted, which today are the
most informative, because allows to define levels microbial content per 1 g. of tissue injury.
Results of the study showed that before treatment in all groups of animals determined by the high level of contamination of tissue wounds, an average of1 x 10 6-9 CFU/g.
On the third day simulation of purulent wounds destructive level of microbial contamination was in the animals of group 1 — 10 5-10 9 CFU/g. The animals in group 2, treated with the standard treatment, on the 3rd day level of microbial contamination was 10 4-10 6 CFU/g. The animals of the 3rd group, which were received treatment PDT only in these terms the level of contamination was on average 10 3-10 6 CFU/g. The lowest level of microbial contamination is observed in the animals of group 4, which was carried out comprehensive treatment with PDT, it was 10 2-10 5 CFU/g.
On the 7th day from the start of treatment ofpurulent wound microbial contamination level ofperformance in the animals of group 1 are without much dynamics. It should be noted that a significant reduction in microbial load of 1 g. of tissue observed in the animals of group 4 (10 2-10 5 CFU/g), compared to the contamination level data tissue wounds of animals in 2nd and 3rd groups (in average 10 3-10 6).
On the 10th day of observation in almost all groups noted a progressive decrease in the level of microbial contamination. However, in the group of animals received a combination treatment of antibiotic therapy with PDT observed sustained reduction in the level of microbial contamination of the wound tissue below the critical. The results suggest greater effectiveness of this type of exposure to destructive purulent wounds as compared to other treatments studied.
Thus conducted studies allow to evaluate the effectiveness of the method of photodynamic therapy of intraoral method of application of the photosensitizer methylene. These laboratory, ther-mometry, morphological, microbiological and planimetric data show, that photodynamic therapy and CO2 laser is very effective non-invasive treatment of purulent wounds and serve as justification for the use of the method in clinical practice for the treatment of local acute purulent- destructive diseases of soft tissues.
References:
1. Gejnice A. V., Tsyganov G. I. Laser technologies in medicine: present and future. Proceedings of the conference, 4-5 December 2014// Laser medicine. - M., 2014. - 18(4): 11-12.
2. Shishkin O. E., Butakova L. Y., Ivanchenko J. O., Antonov S. Microbiological study the effectiveness of the photosensitizers in photodynamic therapy//Laser medicine. - 2013. - 17(1): 35-37.
3. Lapchenko A. S., Malchenko O. V., Kucherov A. G., Lapchenko A.A et al. The method of antimicrobial photodynamic therapy of purulent diseases of the larynx. Patent: 2361633. The Russian Federation. - M., 2009.
4. Kumova I. V., Jmakin A. I., Juk I. G. Microbiological study the efficacy of photodynamic therapy in colorectal surgery//BSMU Medical Journal. - 2007.
Tilyakov Akbar Buriyevich, MD, PhD, Senior researcher of the traumatology department, The Republic Research Centre of Emergency Medicine,
Tashkent city, Uzbekistan Bobur Sobirovich Ubaydullaev, MD, Head of the traumatology department E-mail: akbar-tilak@mail.ru
Diagnostics and treatment tactics of non-stable pelvis injuries
Abstract: Treatment analysis of 415 patients with non-stable and poly-focal fractures of pelvis bones has been described in the article. All patients have been divided to the groups subject to the types of injury, the optimal algorithm of supplying medical aid was worked-out for each group and according to the severity of the combined injuries an appropriate treatment method has
been chosen: external fixation or combined osteosynthesis. The analysis of using different types of pin-rod devices of external fixation has been given. From 182 patients cured with the use of different types of surgical correction the total reposition has been achieved in 114 (62.9 %) cases with exclusive results. In 48 (26 %) cases the reposition was incomplete, an exclusive functional result in this group was achieved in 15 (31.2 %) patients, good result — in 33 (68.8 %) patients. 20 (11 %) patents had bad reposition and in 13 (65 %) cases the result has been estimated as satisfactory one. In 7 (34 %) patients with vertical and rotary unstability the received results were bad.
So, applying an active surgical treatment combining internal and external osteosynthesis of pelvic ring at severe non-stable pelvic fractures with symphysis pubis rupture allows to perform direct reposition and reliable fixation of bones fragments and thereby to provide optimal conditions for early activation, social adaptation and recovery for patients.
Keywords: diagnostics, treatment, non-stable injury, pelvis.
Introduction
The part of highly energetic traumas leading to the multiple and combined injuries constantly increases in connection with an elevation of induced factor of traumatism intensity. One of the main damages at combined injuries are pelvic fractures which occur in 10-40 % cases. There are noticed frequent development of complications (shock, thromboembolic complications, pneumonia, neurotrophic complications) conditioning the high percentage of fatal outcomes — up to 70 % cases [1; 3; 4; 9; 12; 17; 19].
The diagnostics of pelvic bones fractures and acetabulum at performing urgent medical assistance has significant difficulties and it has been proved by the high frequency of clinical and postmortem diagnosis discrepancies [15; 18]. A limited informativity ofX-ray investigation can be increased by the use of special applications offered by P. S. Drachuk (1972) and R. Judet (1981), D. I. Cherkes-Zade with co-authors (1990), A. V. Rumkov (2004), I. L. Shlikov (2004) [7].
Nowadays for successful operative treatment of recent and old pelvic and acetabulum fractures it is necessary to use CT [2; 7; 11; 13; 14; 16] which is not always available to the district level of traumatological service.
Treating ways of pelvic injuries differ by variety but in spite of improving an applied conservative and operative treatment methods, a frequency of unsatisfactory results at severe pelvic injuries even in specialized departments is from 20 up to 38.5 % [1; 2; 4; 7].
Many authors of the aids on treating ofpelvic injuries published in Russian, prefer the methods of external fixation [1; 2; 3; 5; 7; 10]. In the guidances and aids edited abroad, the ways of internal stable-functional osteosynthesis are recommended and apparatus of external fixation or pelvic forceps are mostly used for pelvis stabilization at the emergency medicine during the first "golden hour in shock case" [6; 11; 15; 18; 19].
Adoption of modern technologies into modern orthopedics and damage control has allowed to improve treatment results of the patients with pelvis injuries [2; 3; 4; 9; 10]. Though the frequency of unsatisfactory results of surgical cure of the patients with non-stable pelvis injuries like B and C types according to AO classification at combined injury makes from 20 up to 30.5 % [1; 2; 8; 12; 15; 19].
There is no doubt that non-stable pelvic fractures like B and C types according to AO classification are followed by the loss of its supporting function and they are the indication for operative treatment [7; 12; 17; 19].
So, above mentioned statistics, unsolved issues in choosing optimal ways of pelvis injuries fixation, the absence of bio-mechanical reason for bone fragments fixation define the relevance of the subject and require scientific updating.
Objective
To optimize the diagnostics and to improve treatment results of the victims with non-stable pelvic bones fracture using modern technologies and ways of mini invasive osteosynthesis.
Materials and methods
Data of treatment results of 415 patients with different pelvis injuries. The main quantity 315 (76 %) of patients were at the most capable age — 25-55 years. Males were dominated 302 (73 %) patients and females were 112 (27 %) correspondingly. Considering the fact that the main reason of pelvis injuries were road traffic accidents and fallings from a height, combined and multiple origins of trauma has been pointed in 327 (78.7 %) patients. In 298 of them there were craniocerebral injury of the different levels of severity, chest and lungs injuries — in 90 cases, abdominal cavity injuries — in 84 patients, kidney and urinary bladder injuries — in 72 victims and in 317 patients injuries were combined with extremity bones injuries. 244 patients admitted to the hospital had traumatic shock of different levels of severity.
According to clinical-anatomical types of pelvis injuries and treatment tactics the victims have been divided in three groups by AO Documentation Centre's classification.
The 1st — group: А type — with a minimal displacement, without abnormality of the dorsal part ofpelvic ring integrity; pelvic diaphragm is intact, pelvis is capable to withstand to usual physical activity without a displacement — 178 patients were in this group.
The 2nd — group: В type — rotary-unstable, but vertically stable injuries appeared due to effect on the pelvis lateral compressive or rotary forces. The back group of ligaments and pelvic floor remain intact, there is a possible rotary non-stability, 115 patients were in this group.
The 3rd — group: С type — rotary and vertically unstable injuries characterized by a complete separation of the pelvic ring including back sacroiliac complex. Injury can be one or two-sided, the quantity of victims in this group was 122 people.
All patients with pelvis injuries had been performed investigations and treatment according to the standards with a glance of dominating pathology. Being admitting all patients with combined pelvis injuries have been placed into the shock-room where have been examined by the specialists — traumatologist, neuro-surgeon, reanimatologist, general surgeon, urologist and others according to indications. In the case of non-stable hemodynamics the patients have been performed antishock procedures. Simultaneously there have been carried investigations including intaking analysis (general blood analysis, urine analysis, blood for group and rhesus, biochemical blood analysis and coagulogram), X-ray, USD of internal organs, Echo encephaloscopy, CT and MSCT.
From diagnostic point ofview a complicated surgical intervention in pelvis cannot be based only on convex radiography. We as mane other authors think that spiral and multy-spiral computer tomography (MSCT) has significant advantages due to more volumetric image of injuries nature.
Pelvic bones CT with 3D image we have done with PHILIPS CT «Aura» (2002) in VOLUM RENDERING, slice — 7 mm.,
Table index — 5 mm,. PITCH-1,5 regime and with PHILIPS «Brilliance 40» MSCT (2006) in spiral regime step 3 mm., layer width 3 mm., PITCH-0,6. 163 patients have been performed CT investigations.
X-ray investigation of patients has been done with PHILIPS «Duo DIAGNOST» (2002) stationary X-ray mashine SIEMENS «POLIMOBIL» (2001) portable apparatus. Performing X-ray investigation in oblique view in compare with other existing ways we did not turn the patients to the lateral position and it coul lead to the aggravation of patient's severity condition, this procedure has been done by the tube flexion at the same 45° angle. At severe combined injuries X-ray investigation has been performed at the patient's bed with the help of portable apparatus.
Diagnostics complicity at a combined injury has been specified by diversity, blurring of clinical presentations of abdominal cavity and retroperitoneal injuries. Specific investigations have been used for diagnostics and correct treatment. Clinical analysis of blood and urine are the most informative ones from applied laboratory investigations. USC of urinary bladder and abdominal cavity have been used for indirect signs imaging. Patients with pelvic bones injuries have been performed urinary bladder catheterization, at detection of
blood presence in urine the patients have been performed Zeldovich test. Patients with urinary bladder injuries had positive Zeldovich test. These patients have been done X-ray investigation (urethrogra-phy with ascending cystography in two projections).
Treatment ofpelvic injuries are only the part of general treating procedures. A great attention has been paid to the severity conditions estimation of victims as the majority of patients have admitted in different levels of shock. It is necessary to point that patients' examination has been done against the background of anti-shock therapy and pain relief, intra-pelvic anesthesia by Sholnikov-Seliva-nov has been performed.
Applied treatment methods in patients with pelvic injuries
Dislocations in hip joint have been eliminated after diagnosing under the general anesthesia. Patients with combined injuries, chest and abdominal cavity organs injuries required emergency surgical intervention have been performed operations on cavitary organs and extrafocal osteosynthesis sequentially after eliminating a dominated pathology. At the necessity of an operative correction of extremities fractures and pelvis injuries, one-phased operative intervention has been done with the use of small-invasive ways of osteosynthesis worked out at our hospital (Table 1).
Table 1.
Treatment method Type of injury by АО Total ( %)
А B C
Conservative 111 29 28 168 (40.4 %)
Opened reposition and osteosynthesis 15 23 15 53 (12,9 %)
Transosseous osteosynthesis by external fixation 47 51 60 158 (38 %)
Combined osteosynthesis 5 12 19 36 (8,7 %)
Totally 178 (43 %) 115 (27.7 %) 122 (29.3 %) 415
The first group of patients (A type) as it is seen from the table, have been treated by traditional conservative ways according to the minimal displacements, without continuity damage of dorsal part of pelvic ring and with a nullity anatomic-functional disorders. In this group patients with marginal fractures of iliac crest the osteosyn-thesis has been performed by compressing screws. At pubic branch fractures in the cases with combined injuries of abdominal cavity and urinary tracts (a presence of epicystostomy required an early activation) a front stabilization with light type of clinic's backbone apparatus has been performed. Later patients underwent physiotherapy keeping orthopedic regimen within 4-6 weeks.
In the second group of patients (B type) with rotary-unstable but vertically stable pelvis injuries the ways of mini-invasive tran-sosseous osteosynthesis by our backbone and spoke-backbone apparatus were widely used (Fig. 1, 2). Taking into account the fact that there were no vertical displacements of pelvis half in this patients group and the presence of pelvis injuries on "open book" type they were easily eliminated in apparatus. The optimal way of treatments in this group was osteosynthesis by backbone apparatus. The duration of instrument fixation were 2 months. Patients were activated after 10-12 days. During 3-5 months patients moved with the help of cotters.
Fig. 1. Pelvic fractures fixation device
The third group was consisted of patients with severe rotary and vertically-unstable injuries characterized by complete separation of pelvic ring including back sacroiliac complex (C type). In patients of this group we have used the methods of submersible
external osteosynthesis and the ways of percutaneous osteosynthe-sis of the acetabulum by threaded nails (Fig. 3). Physiotherapy with keeping orthopedic regimen has been conducted according to the duration of pelvic bones biological consolidation.
Fig. 2. Upgraded model of backbone device for non-stable and poly-focal pelvic fractures treatment
Fig. 3. Acetabular and vertically displaced pelvic fractures fixation device
Results and discussions
Totally there have been performed 247 operative interventions. There were used apparatus of external fixation for treating patients with pelvic bones fractures which were worked-out in the Republic Research Centre ofEmergency Medicine. Estimating the reposition quality and recovery of pelvis functions at its non-stable fractures with the use of different types of surgical treatment and their combinations we have determined that the most qualitative reposition and stable fixation has been achieved in patients with B type fractures — 94 patients, C type — 70 people where there have been used the ways of transosseous and external osteosynthesis.
Late fates of patients operative treatment with non-stable pelvic fractures have been studied in 182 patients in the period from 6 months till 3 years. All patients have been operated in early posttraumatic period until 10 days. In all cases the stability of pelvic ring has been recovered and it has been proved by X-ray normal interrelations in symphysis pubis and in sacroiliac joint. Treatment results surely must depend on reposition quality. In 182 patients treated with the use ofvarious types of the surgical correction the complete reposition has been achieved in 114 (62.9 %) cases and there were got excellent results. In 48 (26 %) cases the reposition was incomplete, an excellent functional result in this group was in 15 (31.2 %) patients, a good one — in 33 (68.8 %) patients. 20 (11 %) patients
had bad reposition, in 13 (65 %) cases the result has been estimated as satisfactory one. In 7 (34 %) patients with vertical and rotary-unstable injuries there were bad results.
Conclusion
The diagnostics ofnon-stable pelvis injuries must be complex including clinical and instrumental investigation methods. Applying action algorithm subject to type and nature of injuries, using modern technologies allow to reduce the percentage of diagnostic mistakes and promote the choice of the most optimal treatment method.
Using backbone apparatus of external fixation meets a requirement of the stable osteosynthesis and it is an effective, small traumatic way of pelvis injuries stabilization at the early stage of traumatic disease. Early surgical tactics of treating non-stable pelvic bones fractures with the use of transosseous osteosynthesis and at the presence of indication in the combination with external osteosynthesis allowed to get positive anatomic-functional outcomes in 91.6 % cases.
So, applying an active surgical treatment combining internal and external osteosynthesis of pelvic ring at severe non-stable pelvic fractures with symphysis pubis rupture allows to perform direct reposition and reliable fixation of bones fragments and thereby to provide optimal conditions for early activation, social adaptation and recovery for patients.
References:
1. Agadjanyan V. V., Milyukov A. Yu. Estimation of patients treatment results with pelvis injuries//Herald of traumatology and orthopedics. - 2002. - № 3. - P. 67-70.
2. An R. N., Vinogradov B. V., Blinov I. M. Modern aspects of X-ray diagnostics of pelvis injuries in the condition of peacetime and war-time//Military medical journal. - 2002. - № 12. - P. 21.
3. Besaev G. M. Pelvis injuries in victims with multiple and combined injuries//Author's abstract of dissertation of Medical sciences doctor. - 1999. - 38 p.
4. Ganin B. N. Treatment of multiple fractures of pelvic bones in victims with severe combined injuries by KGT-1 universal backbone apparatus: dissertation of PhD. - 2000. - 217 p.
Genetic polymorphism of cytokines in patients with keloids
5. Gumanenko E. K., Shapovalov V. M., Dulaev A. K., Didikin A. V. Modern approaches to the treatment of victims with non-stable injuries of the pelvic ring//Military medical journal. - 2003. - № 4. - P. 17-19.
6. Didikin A. V. Surgical stabilization of pelvis at injuries: Report about SRW № 200077. - 2001. - 217 p.
7. Dyatlov M. M. Complex pelvis injuries. What to do? - Gomel, 2006. - P. 69-74.
8. Lobanov T. E. Computer tomography in the diagnostics of pelvis injuries//Orthopedics, traumatology. - 1993. - № 3. - P. 72-74.
9. Mineev K. P., Balandin A. N., Marusev A. L. and others. Pecularities of X-ray diagnostics of pelvic ring injuries//Methodical recommendation. - Saransk, 1995. - 5 p.
10. Sokolov V. A., Shetkin V. A. Operative treatment of pubic symphis and sacroiliac joint raptures at mulpiple and combined injuries//Her-ald of traumatology and orthopedics named after N. N. Priorov. - 2002. - № 2. - P. 3-8.
11. Ahovuo J. A., Kiuru M. J., Visuri T. Fatigue stress fractures of the sacrum: diagnosis with MR imaging//J. Eur. Radiol. - 2003. - № 5 - P. 24.
12. Bellabarba C., Stewart J. D., Ricci W. M., DiPasquale T. G., Bolhofher B. R. Midline sagittal sacral fractures in anterior-posterior compression pelvic ring injuries//J. Orthop trauma. - 2003. - № 1 - P. 7.
13. Gillick M. What is your diagnosis? Avulsion and dorsal displacement of greater trochanter and fractures of the acetabulum and left pectin of the pubis//J. Am Vet. Med. Assoc. - 2003. - Vol. 223. - № 3. - P. 303-304.
14. Hilfiker P. R., Marincek B. Traumatic injuries: imaging of abdominal and pelvic injuries//J. Europ. Radiology. - 2002. - Vol. 6, № 12. - P. 1289-1291.
15. Letournel E., Judet R. Fractures of the acetabulum. - Springer.: Berlin Heidelberg, 1993. - 110 p.
16. Loberant N., Goldfeld M. A pitfall in triple contrast CT of penetrating trauma of the flank//Clin Imag. - 2003. - Vol. 27, № 5. - P. 351-352.
17. Ramzy A. I., Murphy D., Long W. The pelvic sheet wrap. Initial management of unstable fractures//J. Emerg. Med. Serv. JEMS. -2003. - Vol. 28, № 5. - P. 68-78.
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19. Ziran B. H., Smith W. R., Towers J., Morgan S.J. Iliosacral screw fixation of the posterior pelvic ring using local anaesthesia and computerised tomograph//J. Bone Joint Surg. Br. - 2003. - Vol. 85, № 3. - P. 411-418.
Sabirov Ulugbek Yusuphanovich, Director of Republican Specialized Science Practical Medical Center of Dermatology & Venereology, Republic of Uzbekistan
Toirov Bobur Akbarovich, Junior researcher Azimova Fatima Vakhidovna, Senior staff scientist E-mail: evovision@bk.ru
Genetic polymorphism of cytokines in patients with keloids
Abstract: An ongoing study examined the DNA of an interleukin-6 (IL-6) and interleukin-1 (IL-1) in patients with keloids. The results of the research of gene polymorphisms S3953T gene IL-1B and G-174C gene IL-6 is a marker of increased risk of developing the disease, in particular, is clearly expressed with homozygous genotype polymorphism G-174C IL-6 gene. Distribution of allele frequencies of genes IL-1^ and IL-6, consistent with the law of the expected Hardy-Weinberg equilibrium (P > 0.05). Keywords: Keloids, homozygous genotype, gene polymorphism.
nuclei of lymphocytes was carried out according to the procedure described in the manual Sambrook et al., with some modifications.
Statistical processing of the results of research carried out by the method of variation statistics using Microsoft Office Ex-cel-2003 program.
Results of the study
In order to determine the frequency distribution of genetic variants of the gene mutation G-174C IL-6 gene, we performed a molecular analysis of DNA among relatively healthy donors and patients with keloids [3]. In 25 patients and 20 apparently healthy donors, G allele of IL-6 gene (G-174C) was found 85 % and 96 % of cases, respectively (Table 1). CC allele gene IL-6 (G-174C) were observed respectively in 15 % and 4 % of cases. In assessing the characteristics of the distribution of genotypes and allelic variants of the IL-6 polymorphism (G-174C) in patients with keloid scars it revealed that the differences in the frequency of alleles and genotypes between patients examined men and women were invalid character. A comparative analysis of the
Currently, one of the urgent problems of dermatology are skin diseases associated with impaired collagen synthesis (keloid), and manifesting the development ofvarious degenerative lesions of the skin, reducing the quality of life [1; 2].
Purpose of the study
Carrying out the molecular genetic studies of genotype polymorphism S3953T gene IL-1p and G-174C IL- 6 gene in patients with keloids.
Materials and methods
An ongoing study examined the DNA of an interleukin-6 (IL- 6) and interleukin-1 (IL-1) in 25 patients with keloids and 20 apparently healthy donors (control group). All the subjects resided in the territory of Uzbekistan and had no family ties between them. Comorbidities in patients with keloids was introduced diseases of the gastrointestinal tract (70 %), iron-deficiency anemia (30 %), diffuse goiter of varying degrees (23 %).
In the first stage extraction was carried out from genomic DNA of peripheral blood lymphocytes. Isolation of DNA from
