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Differential diagnostics of the abnormalities of ureter-vesical segment development in children
in angio surgeon, were observed. 10 people did not receive any medical treatment, others did not regularly take aspirin. No rehabilitation was carried out to patients. By type of reconstructive surgery, and the original state at the time of hospital discharge, patients in both groups were comparable.
After 2 years, two patients from the first group of patients in 1 and 1.5 year went through reconstructive preventive intervention on the previously operated limbs due to stenosis in the zone of the distal vascular anastomosis. 5 patients within 2 years after a femo-ropopliteal bypass were performed surgery on the coronary arteries (2 — LAD stenting, 3 — aortocoronary bypass). One patient in 3 months after surgery underwent amputation at the thigh. Result of treatment: good — at 31.0%, satisfactory — at 50.0%, unsatisfactory — at 19.0% ofpatients. Mortality in the group was 10.0%.
In the second group, three patients underwent through amputation (2 — at the level of the hip, 1 — at the level of the lower leg). In general, the result of treatment in the group rated as good — at 11.0%, satisfactory — at 25.0% and unsatisfactory — at 64.0%. Mortality in the group amounted to 40.0%. The main cause of deaths in both groups were acute myocardial infarction (65%) and stroke (20%). Thus, in patients who have not received systematic monitoring and therapy, a positive outcome of the treatment after 2 years was produced only in 36.0% of patients. Meanwhile, in the group of
patients who were under medical supervision with adequate antithrombotic prophylaxis managed 2 years after femoropopliteal bypass got 45% increase in the number ofpositive results of treatment and 25% reduction in mortality compared to the control group. The findings confirm the need for a full and active postoperative rehabilitation of follow-up of patients after surgical revascularization of the lower limbs straight.
Conclusions. The leading role in the dispensary observation belongs to vascular surgeon who determines the tactics of the patient. It should be emphasized the need for timely detection and correction oflesions of coronary and brachiocephalic vessels, given that this comorbidity is the main reason of m ortality (90.0%).
Thus, in the late postoperative period for the prolongation of functioning grafts full antithrombotic prophylaxis and timely preventive repeated reconstructive surgeries are needed. And in order to increase the life expectancy ofpatients after successful revascularization of the lower limbs, an early detection and surgical correction in the first place, coronary and cerebrovascular disease is needed. Rational drug therapy combined with conventional rehabilitation patients is necessary constantly.
Active follow-up for 2 years after femoropopliteal bypass allowed to increase by 45% the number of positive results of treatment and 25% reduction in mortality.
References:
1. Bokeria L. A. et al. Actual problems of surgical treatment of patients with critical limb ischemia -solutions (state the problem).//An-nals of surgery. - № 1. - 2011. - P. 5-9.
2. Bokeria L. A. et al. The role of the rehabilitation of patients with atherothrombotic lesions of the lower extremities in an outpatient setting//Proceedings of the eleventh scientific conference outpatient surgeons Moscow and Moscow region, 2010. - P. 137-138.
3. Diveev V. A. et al. Correction of endothelial function in the complex treatment of patients with atherothrombotic lesions of the lower extremities//Proceedings of the eleventh scientific conference in Moscow clinics and surgeons Moscow region. - 2010. - P. 118-120.
4. Kovalenko V. I. et al. Comparative evaluation of the transplant in the femoropopliteal bypass surgery in patients with critical lower limb ischemia//Proceedings of the Seventeenth Congress of the All-Russia cardiovascular surgeons. - Moscow. - 2011. - P. 113.
5. Kalitko I. M. Repeated reconstructive surgery occlusion in femoropopliteal segment//Annals hirurgii. - 2011. - № 3. - P. 41-44.
6. Klimovich L. G. et al. The differentiated approach to the correction of hemostasis in patients with critical lower limb ischemia.//Pro-ceedings of the Seventeenth All-Russia congress of cardiovascular surgeons. - Moscow. - 2011. - P. 204.
7. Rasulov U. A. Surgical treatment of lower limb ischemia. - Tashkent: "TURON-IQBOL", 2016. - 192 p.
Rakhmatullayev Akmal Abadbekovich CMS, Senior lecturer of the Department of Faculty Children's Surgery, Tashkent Pediatric Medical Institute E-mail: mbshakur@mail.ru
Differential diagnostics of the abnormalities of ureter-vesical segment development in children
Abstract: In case of suspicion of ureter-vesical abnormality it is recommended to use ultra-sound diagnostics, transformation echopyeloscopy with diurrhetic load, impulse-wave Doppler-metering of uretral emission, excretory urography with catheterization of bladder for the time of the test, roentgenocinematography, hydro dilatation and prophylometering, which provide differentiation of the kinds of the pathology impairments in children.
Keywords: children, abnormality of ureter-vesical segment, differential diagnostic.
According to some authors' opinion majority of children with non-reflux form mega ureter widening disappears after some time and does not demand surgical treatment. Obstruction in these patients has functional character and it is conditioned by UVS immaturity [2; 3; 4].
Though many works note late diagnostics of vesical-ureter reflux. Consequently there is high percentage of chronic renal failure
and nephrogenic hypertension leading to invalidity and often death of patients in young age [1; 5].
Taking into account the aforesaid, the objective of this work was design of differential-diagnostic criteria of UVS obstruction in children.
Materials and methods. Retrospective and prospective studies were performed in 161 patients in the age from 3 months to 15 years
Section 7. Medical science
old diagnosed with ureter hydronephrosis, hospitalized to surgery unit of TashPMI clinic and RSSPMC of Pediatrics from 2009 to 2015. As a result, 94 (58.4%) patients had left-side lesion of ureter, 53 (32.9%) — right-side and 14 (8.7%) patients had bilateral lesion.
In the process of the study the tested patients were divided according to the character of UVS obstruction to the following groups: 1st group — 53 (33%) patients with organic obstruction (stenosis of internal vesical part of ureter (45%), stenosis of intra-mural part (35%), uretrocele (20%); 2nd group — 31 (19%) patients with functional obstruction (absence of stenosis and reflux with compensated mega ureter); 3rd group — 77 (48%) patients with dynamic obstruction, i. e. impairment of UVS anti reflux mechanism (PMR).
For the diagnostics of the variants of ureter-vesical segment impairments we applied routine and special research methods. Routine research methods included: common and biochemical blood analysis (electrolytes, urea, creatinin, total protein, bilirubin); urine analysis (qualitative and quantitative, degree of bacteruria and micro flora sensitivity to antibiotics); ultra-sound study (USS) of kidneys and urinary ducts; measurement of the rhythm of spontaneous urinations (uroflowmetering); mixed cyst urography and excretory urography.
For the confirmation of the obstruction character we performed special research methods including transformation echopyelogra-phy with diurrhetic load, USS of ureter emissions with the help of impulse-wave Doppler-metering; excretory urography with catheterization of bladder for the time of testing; roentgenocinematog-raphy, and hydro dilatation with prophylometering of UVS.
Results and discussion. Small descriptiveness of the routine diagnostic methods of UVS developmental abnormalities, or subestimation of its degree leads to unjustified prolongation of conservative therapy and progressing of renal complications.
Comparative characteristics of the examined groups showed, that ultra-sound picture of the kidneys in the children of the 1st group with limited area of obstruction in distal part of ureter, different from these results in the children of the 2nd and 3rd groups, and it was characterized by increased echogenity of the cortical layer, widening of calicies-pelvic system, complete widening of ureter, twisting, thickening of ureter's wall and layering of the structure. Widening of ureter was determined independently of the fulfillment of the urinary bladder. Though the presence ofureter contraction testified maintenance of its function. In the children of the 2nd group ultrasound picture ofkidney was characterized by moderate widening or deformation of calicies-pelvic system. More expressed widening of ureter was determined in distal parts without alterations of its wall and maintenance of peristalsis. While the patients of the 3rd group had growing widening of CPS and ureter in the process of urinary bladder fulfillment; it disappeared after its void proving dynamic type of the obstruction. While performing transformation echo-pyeloscopy in the children of the 1st group the maximal widening of CPS and ureter was registered at the 15th minute of the test and composed 35-60% of the original size (average 43%) and reverse to original sizes did not occur till 60-90th minute. The analysis of transformation echopyeloscopy showed that the more expressed is the original dilatation of ureter the less widening it has at the moment of the study. Children of the 2nd group had maximal widening of the distal part of ureter (25-40%) was noted at the 15th minute of the test from original size and recovery of original sizes occurred till 45-60th minute. In these patients widening of ureter's diameter within the study period did not exceed 1.5 cm testifying preserving tension of its wall. Children of the 3rd group had no notable widening of CPS and ureter and recovery of the original size occurred to the 15th minute.
In impulse-wave Doppler-metering ofureter emission in the children of the 1st group we revealed significant decrease of its frequency (not more than 1 elaculation per 2-3 min), prolongation of the time (3.54±0.18sec) and decrease of the maximal velocity of ejaculation (0.22±0.02 m/sec). At the same time there is notable wide variation of IR values — from 0.43 to 0.85. In children with limited obstruction these alterations are conditioned by expressed dysplastic processes in the wall of ureter. In the children of the 2nd group frequency and duration was close to normal values (2-3 ejaculations per 1 min, T-1.8±0.4sec, Vmax — 0.34±0.03 m/sec). variations of IR values reached maximally 0.78 conditioned by immaturity of muscular wall of the distal part ofureter. Different from the abovementioned groups children of the 3rd group had symptoms of dynamic obstruction: decrease of the frequency to 1-3 ejaculations per one min., or retro flow of urine to distal part of ureter, diminishing of ejaculation time (1.54±0.18sec) and maximal velocity (0.22±0.02m/sec).
In the analysis of the values of excretory urography with catheterization of urinary bladder for the time of the test in the children of the 1st group we revealed symptoms of organic obstruction (significant impairment of urodynamics, supra stenotic widening of ureter along its length and deviation, decrease of of evaculation function of ureter more than 90 min). Children of the 2nd group had moderate widening of CPS. Widening of ureter was more expressed in distal part with absence of deviation; the time of complete contrast evacuation was not more than 45 minutes. Difference of these values for the patients of the 3rd group was in in-time contrast evacuation from ureter.
The performed roentgenocinematography of the patients of the 1st group revealed weak or chaotic cystoids contraction with anti peristaltic motions of ureter, with preserving contrast in the lower one third ofureter. Roentgenocinematography of the children of the 2nd group showed presence of cystoids contraction of ureter with incomplete propulsation of urine to urinary bladder in each contraction linked with UVS immaturity, while the patients of the 3rd group had wide opening of UVS, supply and advance of the contrast with complete relief of the lower one third from the contrast.
For transurethral little invasive tests we applied hydro dilatation and prophylometering of UVS. While having hydro dilatation the patients of the 1st group, different from the patients of the 2nd and 3rd groups, had no opening of the orifice. The values of prophylom-etering showed peak pressure (above 20cm w.c) in intramural and sub-mucous parts of ureter, which indicated organic obstruction; while in the 2nd group there was moderate rise (14-20cm w. c.). The results of the 3rd group children were characterized by opening orifices, visualization of intramural and extra mural parts, and pressure equal to 8-12 cm. w. c.
The achieved results of the special research methods serve for differential diagnostics of ureter-vesical segment developmental abnormalities. The character of UVS obstruction should be determined on the basis of assessment of the symptoms of calicies-pelvic system and ureter widening, its conductibility and functional status.
Conclusion: Special research methods including ultra-sound diagnostics, transformation echopyelography with diurrhetic load, impulse-wave Doppler-metering of ureter emission, exceretory urography with catheterization of urinary bladder for the time of the test, roentgenocinematography, hydro dilatation and prophy-lometering of UVS provide clear differentiation of the kinds of UVS impairments (organic, functional, and dynamic obstruction) in children in any age groups. That will provide achievement of better quality results in the diagnostics and choice of therapeutic method for that pathology in children.
Ultrasonography research of knee joint injury
References:
1. Aliyev M. M., Sapayev O. K., Terabayev B. A., Rakhmatullayev A. A. Protocols of checking of the children with congenital supra vesical obstruction at the various stages of medical aid. Pediatrics. - T., 2006; 3-4: 85-87.
2. Dvoryakovski I. V., Zorkin S. N., Dvoryakovskaya G. M., Tsigina Y. N. The role of ultra-sound diagnostics of kidneys in widening of collecting system in new-born babies. The problems of diagnostics in pediatrics. - M., 2010; V 2;1: 30-33.
3. Canning D. A. British Association of Paediatric Urologists Consensus Statement on the Management of the Primary Obstructive Megaureter. J Urol. 2015 Aug; 194 (2): 518.
4. Iushko E. I., Strotskii A. V. Primary obstructive megaureter of newborns and infants: diagnosis, treatment, follow-up. Urologiia. 2011 Jan-Feb; (1): 63-67.
5. Halachmi S., Pillar G. Congenital urological anomalies diagnosed in adulthood -management considerations. J. Pediatr Urol. 2008 Feb; 4 (1): 2-7.
Rustamova Umida Mukhtarovna, PhD, senior researcher Head of X-ray diagnostic department of the Research Institute of Traumatology and Orthopedics Uzbekistan, Tashkent E-mail: rustamovaum@mail.ru
Ultrasonography research of knee joint injury
Abstract: Ultrasonographic studies were conducted in 468 patients with complaints of pain in the knee joint between the ages of 35 to 58 years (mean age 48 years). Traumatic injuries are identified as fractures joint, tendon ruptures quadriceps, gap lateral ligaments and the patellar tendon, meniscus damage, as well as changes that may be accompanied at these injuries. Semiotics joint damage elements are described.
Keywords: ultrasonography, knee joint, traumatic injuries, meniscus damage, synovitis, bursitis, partial tears of ligaments.
Introduction. The study of literature suggests that there is a little science-based information about the differential diagnosis of knee joint pathology. In many scientific publications, the main aspects of the use of ultrasonography in the diagnosis of injuries and other changes in the structures of the knee joint are shown (Eskin N. A., 2001; Bruhanov A. V., 2006). However, the problem of complex radiation pathology diagnosis of soft tissue structures of the knee joint remain insufficiently studied. Until now, no data regarding comparative analysis of diagnostic efficacy of ultrasonography and radiography of soft tissue injuries in the structures of the joint. Indications for use of radiographic diagnosis is not defined, clinical diagnostic algorithm of x-ray examination of patients with soft tissue injuries and bone structures of the joint is not designed. Investigation of the knee joint through the application of digital radiographic and ultrasonographic techniques, development of differentiated criteria for various types of joint pathology and put them into practical health care, in our opinion, is one of the most important preventive health trends of the population.
Purpose of research — Studying the state of elements of the knee joint during his traumatic changes.
Materials and methods of research. The basis of the research on these urgent issues is the results of comprehensive clinical, ultrasound, X-ray examination of patients with different types of traumatic changes of the knee joint structures. Ultrasonographic studies were conducted in 468 patients (574 hips) with complaints of pain in the knee joint between the ages of 35 to 58 years (mean age 48 years). Ultrasonic diagnosis conducted with MyLab-40 Company Esaote apparatus (made in Italy) by applying the method polypositional multifrequency linear transducer 7-12 MHz. During sonography of knee joint, we followed the mandatory requirements. In the beginning — the sick man on his back, knee examined first of several joint flexed about 30 degrees and in the
unbent state it, then survey the patient on his stomach with a straightened limb.
Results and discussions. Based on the study results of studies, we identified ultrasonographic changes in knee injury and the following semiotics are developed: During bone fractures of joint, hyperechoic contours are interrupted with the presence of hypo-or anechoic stripe or area, and when mixed fragments hyperechoic contour is deformed.
Gap quadriceps visualized with heterogeneous structure, while there is a violation of stroke fibers, existence of anechoic areas — hematomas, thickening of the muscle layers. Partial rupture is distinguished presence of micro hematoma and muscle thickening. Tendon rupture of the quadriceps femoris: it is not smooth contours, structure is uniformed, with the presence of anechoic areas, hematomas, and violation of interruption of the fibers, thickening of the tendon. Partial rupture of the tendon of the quadriceps femoris — contours equal or not equal, sometimes interrupted circuit on the one hand, the structure is uniformed, with the presence of micro-anechoic — micro damages, bruises, and a violation of interruption of the fibers, thickening of the tendon.
At breaks of lateral ligaments and the patellar tendon differentiated this picture: contours are not smooth, the structure — uniform, with the presence of anechoic areas, bruising, deformity and interruption of the fibers, thickening of ligaments. Partial tears of ligaments and the lateral patellar tendon looked with equal or even, sometimes discontinuous contours on the one hand, the structure with non-uniform, with the presence of micro-anechoic — micro tears, bruises, broken and interrupted the course of the fibers, ligaments thicken.
Above the knee bursitis visualized with smooth and crisp exterior contours, while often thickened synovium, the inner contour is usually uneven. Above the knee bag is extended and thickened, in-
