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6children, transient in 18 (6%) children. According to the history of this severe course of pregnancy observed in 14% of cases; family history on the part of the cardiovascular system - in 22% of cases.
From accompanying diseases are most common: posture disorder in 22% of children, changes in the thyroid gland (according to US) in 96 (32%) children, renal pathology in 20% of children (mostly dysmetabolic nephropathy), a variety of allergic reactions were detected in 20 % of children. The diagnosis "frequently ill child" exhibited in 168 (56%) children, of whom 100 children identified pockets of chronic infection: chronic tonsillitis - 60 children, caries - in 22 children, chronic sinusitis - 16 children, chronic pyelonephritis - in 2 children . Carriage St.aureus detected in 12% of children.
The main complaints: pain in the heart - 35% of people, fatigue - 22% of people, the heartbeat during exercise - 11% of people. Note that 32% of children with a diagnosis of myocardial observed, do not make subjective complaints.
An objective study revealed 60 (20%) people who are overweight, 18 people (6%), obesity 1 tbsp. and 36 children (12%) underweight. Systolic murmur at the apex to listen to 29% of children at the point Botkin - 11% of children. Increased thyroid 1-2 tbsp. diagnosed in 81 children (27%).
In 60% of children (180) according to the history, examination, and the results revealed CIG dystonia: the girls mostly on the mixed type, and the boys - mainly on vagotonic type.
According to ECG abnormalities were observed in 285 (95%) patients, of which the most frequently encountered: the conduction slowing right leg bundle branch block - 186 (62%) patients, early repolarization of the ventricles - in 159 (53%) patients, the metabolic changes myocardium - 105 (35%) patients and various arrhythmias, including bradycardia - in 114 (38%) children, tachycardia - in 48 (16%) children. ECG exercise was conducted in 162 (54%) children, 82 (51%) of them after exercise revealed sinus tachycardia, in 27 (17%) patients were isolated supraventricular extrasystoles, bradycardia was observed in 48 (30%) children.
Thyroid ultrasound performed on the testimony from 246 children (82%). The most common changes in the thyroid gland (according to US): an increase in size of the prostate, a gland parenchyma structural changes. Evaluation thyroid hormone status held only 87 children, 80 of them, i.e. 91.9% identified the changes in hormone levels (increased TSH, T4), TPO antibodies were found in 24 children (27.6%).
According to the ultrasound of the heart revealed hyperechoic inclusions in the interventricular septum in 98.3% of children; mitral valve prolapse, 1 tbsp. with minimal regurgitation in 126 (42%) children, the seal mitral valve 52 (17%) children, abnormally located chord left ventricle 186 (62%) children, patent foramen ovale (5 mm) in 33 (11%) children, reduced contractility of the left ventricle in 2 children (0.6%).
Because on our work conclusions can be drawn that the MCD is polietiologic disease that is more common in the sickly children, children with chronic foci of infection, and is closely related to diseases of the thyroid gland (which manifests itself in our study of undifferentiated connective tissue dysplasia syndrome small heart anomalies), with malnutrition. MCD in 60% of cases combined with autonomic dysfunction syndrome. The absence of subjective complaints of a third of patients do not exclude the presence of this pathology in the detailed survey: 95% of children with MCD have deviations ECG parameters and in 98% of children in the US change of heart. Children with this disease require special attention from the pediatrician.
Literature
1. Belyaeva LM Myocardial dystrophy in children and adolescents / LM Belyaeva, EA Kolupaeva, EK Hrust-aleva // Medical News. 2010. №2. - S.34-39.
2. Leontiev IV Lectures on pediatric cardiology / IV Leontief. - Moscow: Publishing House of Medprakti-ka-M, 2005. 536 p.
3. Russian recommendations. Prevention of cardiovascular diseases in childhood and adolescence // Russian Journal of Cardiology. 2012. № 6 (98). Annex 1.
DOI: 10.22448/AMJ.2016.15-16.43-46
UDC 616
EVALUATION OF REPEATED CYTOREDUCTIVE SURGERY AT RECURRENCE OF OVARIAN CANCER
Gavrilov A.S., Konstantinova M.Y., Boldyreva O.S.
Amur State Medical Academy, Blagoveshchensk, Russia, Amur Regional Oncology Center, Blagoveshchensk, Russia
Abstract Despite the introduction of modern methods of treatment, mortality in ovarian cancer occupies the first place in the structure of mortality from gynecological cancer diseases.
Repeated cytoreductive surgery increases the survival of patients with recurrent ovarian cancer with the I - III stages, platinum, in the absence of metastases in the liver and pleura disease at recurrence, the implementation of optimal cytoreduction and objective tumor response to chemotherapy.
Key words: ovarian cancer, recurrence, second cytoreductive surgery
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The incidence of ovarian malignancies remains high and occupies the 3rd place in the structure of on-co-gynecological pathology. Despite the introduction of modern methods of treatment, mortality in ovarian cancer took first place in the structure of mortality from gynecological cancer diseases. In the first year of life from the time of diagnosis of 27.4% of the patients die. The main cause of death is a recurrence of the disease.
For the treatment of recurrence malignant ovarian tumors are various methods used. The advisability of chemotherapy in recurrence ovarian cancer is generally recognized. At the same time, the evaluation of the effectiveness of the combined treatment of ovarian cancer recurrence remains one of the most discussed issues in gynecological oncology. Several studies have demonstrated that when repeated cytoreductive operations significantly increases survival in patients recurrent ovarian cancer. The highest value in the prediction of treatment outcomes given the size of the residual tumor and its sensitivity to chemotherapy. Overall survival of patients is much higher when the complete cytoreductive surgery with a minimum size of residual tumor. This position is confirmed in other studies.
Most researchers emphasize the need to perform surgery in patients with recurrent ovarian cancer as the most effective method of eradication of the tumor and create favorable conditions for chemotherapy. In order to achieve minimal residual disease in patients with recurrent ovarian cancer with regional and distant metastases widespread recombined cytoreductive surgery, the most commonly performed on the gastrointestinal organs. At the same time there are contradictory evaluation results of the combined treatment (surgery + chemotherapy) for recurrent ovarian cancer. In the works of P. G. Rose et al. (2014) and M. E. L. van der Burg et al. (2007), comparing the results of the combined treatment of recurrent ovarian cancer and chemotherapy, no significant difference in median overall survival between the groups. The median life expectancy in the combination therapy was 36 and 26 months in chemotherapy - 35.7 and 20 months. Thus, finally, it is not clear that the impact on the survival of these patients: surgery, or biological characteristics of the tumor and the microorganism.
The purpose of this study: evaluation of repeated cytoreductive operation and identification of the factors that determine the survival of patients in the combined treatment of recurrent ovarian cancer.
Materials and methods The study included 35 patients treated in Amur Regional Oncology Center for recurrent ovarian cancer from 2008 to 2014. Initially, all patients underwent combined treatment (surgery + chemotherapy or neoadjuvant chemotherapy + surgery + chemotherapy) chemotherapy with platinum-schemes: platinum drugs + cyclophosphamide or platinum plus paclitaxel formulations. Platinum-resistant patients were 17, platinum-sensitive - 18.
At recurrence of the disease combined treatment (re cytoreductive surgery + chemotherapy) held on 18 patients. In this group I-II ovarian cancer stage was in 5 patients, III-IV - in 13. In histological type patients were distributed as follows: serous adenocarcinoma - in 9, mucinous - at 5, endometrioid - at 3, clear cell - in 1.
The tumor at recurrence disease was localized in the pelvis in 3 women in the abdominal cavity without damaging the liver parenchyma - at 10. Distant metastases identified in 5 cases. The following surgical procedures were performed: 3 - extirpation of the cervical stump resection or resection of the vagina and the excision of the tumor, 2 - lymphadenectomy, 13 - excision of the tumor mass. In 7 patients the operation was supplemented by surgery on the gastrointestinal tract (combined operations) organs: colon resection with anastomosis - in 3, resection of the colon with the formation of a colostomy - in 2, resection of the small intestine with anastomosis - in 1, appendectomy - in 2.
Chemotherapy treatment performed under the combined 18 patients 10 patients on schemes CP (cisplatin and cyclophosphamide), CC (carboplatin and cyclophosphamide) and CAP (cisplatin, doxorubicin, cyclophosphamide); 8 patients combinations containing platina and taksan (TP).
In 17 patients with ovarian cancer recurrence chemotherapy carried out as a self-treatment. Within this group I-II stage of the disease in 7 patients was, III-IV - in 10 patients. According to histological type of tumor were distributed as follows: serous adenocarcinoma was in 12 patients, mucinous - at 3, endometrioid - at 2. The tumor at recurrence of the disease was localized in the pelvis in 2 patients, in the abdominal cavity without parenchymal liver - 8. Distant metastases detected in 7 cases.
In this group, the chemotherapy was conducted under the following schemes: CP or CAP in 9 patients, TR (cisplatin and paclitaxel) - in 9 patients. .
In both groups, all patients with platinum-resistant recurrence was replaced by cytostatic treatment regimen to second-line regimens: the CP to the TP, TP at ATS. In the case of platinum-sensitive recurrence was used first-line scheme - SR / SS or TR.
Compared groups were balanced with each other on the main factors that can influence the results of treatment.
In order to identify the factors influencing the survival of patients during repeated cytoreductive operations, operated patients were divided into 2 groups. The 1st group included 7 patients with overall survival did not differ from that of the group of patients who underwent chemotherapy as a self-treatment. In group 2 there were 11 patients with survival, greater than that in the group of patients who underwent chemotherapy.
In the following group of operated patients were analyzed according to the main characteristics of the method of "case-control". As a direct criterion of efficiency of treatment used overall survival - survival from the date of detection of disease recurrence to death; as an indirect criterion - evaluation of the effectiveness of chemotherapy. By platinum attributed recurrence occurred after 6 months or more after the end of the previous platinum-based chemotherapy; to platinum-resistant - have arisen in the next 6 months after platinum-based chemotherapy. The optimality of operations determined in accordance with the rules of the International consensus on ovarian cancer (1998) and GOG: optimal cytoreductive surgery - residual tumor 1 cm or less, suboptimal - residual tumor larger than 1 cm.
Results In the combined treatment of recurrent ovarian cancer complete tumor regression was achieved in 9 patients, partial response - in 4, stable disease - in 3. Progression of the disease was observed in 2 patients. Chemotherapy as a self-treatment, these figures were as follows: complete regression of tumors - in 5 patients, partial response - in 2, stable disease - in 3. Progression of the disease was observed in 7 women. Objective response to cytotoxic therapy was achieved in 13 operated patients and 7 patients in the group without surgery treatment. In the study of long-term outcomes after combined treatment and chemotherapy were obtained statistically significant differences between the groups in total 5-year survival rate, which in the combination group was 9% (median survival 39 months). In the group of patients treated with chemotherapy, there was no patients surviving more than 5 years. The median overall 5-year survival in this group was 18 months.
However, in the combination-therapy group were patients with survival rates did not differ from that of patients who received chemotherapy as a self-treatment. To identify factors that influence the survival of operated patients, the combination group was divided into Group 1 patients (n = 11) with a survival rate equal to the survival of patients who received chemotherapy alone as a self-treatment, and group 2 (n = 7) with survival, was significantly higher than the survival rate of patients who received chemotherapy alone.
Subsequently, the 1st and 2nd groups of combined treatment were compared with each other by the "case-control" on the main features characterizing the patients in these groups.
In the 2nd group of patients operated compared with the 1st group was dominated by patients with stage I-IIIb disease. Within this group I-IIIb ovarian cancer stage was at 6 women, IIIc-IV stage - at 1. In Group 1, where the overall survival was the same as in patients who underwent only chemotherapy with stage I-IIIb were 6 patients with stage IIIc-IV - 5. A statistically significantly 1st and 2nd group differed in sensitivity to platinum-schemes. In group 2, all patients were platinum in group 1 - platinum-3 were women, and platinum-resistant - 4. In the 2nd group of patients revealed no distant metastases at recurrence of the disease. All patients diagnosed with local or locally advanced disease recurrence. In group 1, the local or locally advanced recurrent ovarian cancer was only in 7 patients, and 4 revealed distant multiple metastases in the liver parenchyma and pleura.
During the surgery, 6 patients in group 2 made repeated optimum cytoreductive surgery. Suboptimal operation in this group were only 1 patient. In group 1 patients predominated, which made repeated suboptimal cytoreductive surgery - at 8. Optimal cytoreductive surgery was in 3 patients.
In terms of the effectiveness of chemotherapy for recurrent disease, these groups are also significantly different. In group 2, complete tumor regression was achieved in 4 patients, partial response - in 2, stable disease - in 1. 1st these indicators group were significantly lower: complete regression of tumors - in 2 patients, partial response - in 1, stable disease - in 3. Progression of the disease during treatment were observed in 5 patients in this group.
According to ECOG status, histological type and tumor grade revealed no statistically significant differences between treatment groups operated patients with different survival. Status ECOG 0-1 were all (100%) patients in group 2. This figure is in group 1 was in 8 women, and the status ECOG 2-4 were 3 women. According to histological type of tumor, patients in group 2 were distributed as follows: serous adenocarcinoma - in 5 patients, mucinous - at 2. In group 1 serous adenocarcinoma was in 4 patients, mucinous - at 3, endometrioid - at 3, mezonefroidnaya - in 1.
Discussion This study demonstrated the advantage of combined treatment of ovarian cancer recurrence compared with chemotherapy, which once again confirms the findings of other authors about the important role of cytoreductive repeated operations for recurrent ovarian cancer. At the same time a group has been allocated operated patients in whom combination therapy was effective as well as chemotherapy. As a result, we identified a number of symptoms associated with an increase in the effectiveness of the combined treatment of ovarian cancer recurrence. One sign was the stage of the disease. It was shown that did not affect the overall survival of patients with recurrent IIIc-IV stage of the disease repeated cytoreductive surgery. Perhaps this was due to the fact that the stage of the disease is associated with the size of the residual tumor after repeated cytoreductive surgery. The size of residual tumor after repeated cytoreductive surgery was one of the main factors affecting the long-term results. Implementation of optimal cytoreductive surgery provides the advantage in survival after combined treatment group compared with patients treated with chemotherapy.
No less important for the survival of the patients was and the nature of tumor metastasis in recurrence disease. There was no increase in overall survival after surgical interventions in the localization of multiple
Амурский медицинский журнал №3 - 4 (15 - 16)
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metastases in the liver and pleura. Forecast disease at recurrence of ovarian cancer is also a measure of sensitivity to chemotherapy. All patients had platinum-sensitive patients in the combined treatment with survival greater than the survival of patients who only received chemotherapy. This is probably determined the effectiveness of chemotherapy in patients with recurrent ovarian cancer with a "high" survival during the combined treatment.
Conclusions Repeated cytoreductive surgery increases the survival of patients with recurrent ovarian cancer stage I-IIIb, while platinum tumors in the absence of multiple metastases in the liver and in the pleura, with a residual tumor less than 1 cm and the objective tumor response to chemotherapy.
DOI: 10.22448/AMJ.2016.15-16.46-47
UDC 616-099
THE MORPHOLOGY OF SOME ORGANS IN CASE OF COMBINED INTOXICATION OF ALCOHOL AND
DRUGS Gigolyan M. O., Cheryomkin M. I.
Amur State Medical Academy, Blagoveshchensk, Russia
In forensic practice there is observed increase in mortality from poisoning by narcotic substances and alcohol. One of the most actual problems of forensic medicine is the development and improvement of methods of diagnosis of acute and chronic drug intoxication (ANI, CNI) [4]. In the literature there is not enough study of morphological changes in ANI and CNI [2, 3]. However, data on morphology of combined intoxication with alcohol and drugs are controversial and insufficient. According to the literature, 79-82,6% of drug addicts with chronic hepatitis and 100% with cirrhosis of the liver abused alcohol [5,6,7].
The aim of our study was to investigate morphological changes in concomitant chronic intoxication with alcohol and drugs.
Materials and methods We studied 38 corpses of persons of both sexes suffering from chronic narcotic intoxication aged 18 up to 45 years old. CNI diagnosis was confirmed on the basis of forensic-chemical studies in the internal organs and biological fluids of corpses with the identification of narcotic substances from the group of opiates (morphine, heroin, codeine) as well as the diagnosis of CNI was confirmed by the data of cat-amnesis, the presence of multiple traces, at different stages of injection injuries. In 22 cases of investigated corpses (60%) in blood it was found the ethyl alcohol in a concentration from 0,9% up to 2,2% and identified narcotic substances from the group of opiates (morphine, heroin, codeine). To study the relationships between alcohol consumption and morphological changes of internal organs with the drug, we allocated 2 groups: 1) the dead from isolated acute poisoning by opiates (16 people), which served as the comparison group; 2) the combined deaths from acute poisoning by alcohol and opiates (22 people). In the control group in 15 cases it was used individuals aged 20-35 years old (12 men and 3 women) never used drugs and died from mechanical asphyxia. Evaluation of morphological changes of internal organs was performed by comparing on Student's criterion. There was produced macroscopic examination according to the Shore method. For microscopic examination the taken tissue were fixed in 10% neutral formalin and subjected to standard paraffin conducting. The preparations were stained with hematoxylin and eosin, Mallory and Perlsu, picrofucsin by Van Gieson with subsequent morphometric studies.
The results of the study
Morphologic study of the majority of drug usersidentified a range of changes, whichaccording to the literature was common in alcoholic disease [1]. Puffiness of the face, muciform, gelatinous mass covering the wall of the stomach, enlarged liver with a yellowish tinge, the increase in the fat layer of the heart, enlargement of heart chambers, the consolidation of the pancreas.
Microscopic examination revealed hepatic steatosis, diffuse fibrosis and lipomatosis of the stroma of the pancreas, diffuse cardiosclerosis, irregular hypertrophy of the myocardium, marked lipomatosis of the stroma of the myocardium, fragmentation of cardiomyocytes. Basal inlay ofnephrothelium, thinning of the adrenal cortex occurred from 40% up to 90% of cases.
Morphologic changes in the main group (the combined toxicity of by alcohol and opiates) were significantly more frequently than in the comparison group (isolated opiate toxicity): 1) in the heart - a significant increase in the fat layer (70 and 32% of cases), uneven myocardial hypertrophy (in 100 and 70% of cases), the extension chambers of the heart (in 56% of cases in the main group and 31% in the comparison group), fragmentation of cardiomyocytes (in 88 and 56% of cases); 2) in the lungs -hemosiderosis of the lungs (45-25% of cases); 3) in the brain there is marked fibrosis of the meninges (in 76-36% of cases), vascular changes with impaired permeability (in 56-22%); 4) in the liver - diffuse fatty infiltration, steatosis of the liver.(in 69-29%); 5) in the adrenal glands - the thinning of the crust, the accumulation of brown pigment(in 71-35% of cases); 6) in the kidneys - basal inlay ofnephrothelium (67-27% of cases); 7) in the pancreas - the consolidation of the pancreas (62 and 26% of cases), marked fibrosis and lipomatosis of the stroma of the pancreas (in 85 and 58% of cases), (p > 0.05 for all the listed signs).
