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11dominated by people of working age. 90 dead, depending on the type of drug resistance were divided as follows: I-group with monorezistents are 20 people, with poliresistants - 34 people, III-multi-drag-resistants (MDR) 36 people.The comparison group were the 15 people who died of pulmonary tuberculosis with the stored drug sensitivity.
The objects of study were pieces of equity and segmental bronchi. The material was fixed in 10% neutral formalin, dehydrated in alcohols of increasing strength and embedded in paraffin by standard techniques. Morphometric analysis was performed on histological sections of a thickness of 5 microns. An overview paraffin sections stained with hematoxylin and eosin.
Results and discussion: Thesedata suggest that the severity of these changes depends on the bronchi resistance and duration of the disease. In the group with poliresistans and multidrug-resistant tuberculosis with a duration of one to five years, a marked lymphocytic-macrophage infiltration of the mucosa. The same dependence on the type of drug resistance and duration of the process identified by morphometric study by the bronchial glands (glands hypertrophy with an increase in the diameter of the mucous departments).
Dependence on the drug resistance is expressed not only in quantitative but also qualitative changes in the cellular composition. Infiltration of pulmonary tuberculosis multidrug-resistant cells is composed exclusively of lymphocyte-macrophage type. Pulmonary tuberculosis with the stored drug-sensitive and duration of tuberculosis for more than five years of morphologically defined pronounced fibrosis in the wall of the bronchus often "limfonoduli" having the structure of the follicles of lymph nodes with the same melkopetlistym reticular core and a bright germinal center. In groups with poliresistan and multidrug-resistant these changes are extremely rare.The results obtained in the study suggest that, in conditions of prolonged antigenic stimulation with fibro-cavernous pulmonary tuberculosis with drug-resistant stored in bronchial tissue creates a local source of immune cells. Thus, the analysis of the results of its own research and the literature allows us to characterize non-specific bronchitis, pulmonary tuberculosis as an expression of immune reactions, with the formation of structures that are similar to the central authorities immunogenesis. And, apparently, for many conditions, morphologically defined as chronic inflammation may be a manifestation of immune response with prolonged antigen located.
References:
1. Blum NB, Ariel BM et al. Specific and non-specific bronchial lesion and lymph nodes as a manifestation of synergies limfoepitelialnogo system in pulmonary tuberculosis. / / Problems of Tuberculosis and Lung Disease. - 2008. - № 12. - Pp. 8-12.
2. Blum, N., Y. Kirillov Morphological characteristics of specific and non-specific lesions of intrathoracic lymph nodes in pulmonary tuberculosis. / / Problems of tuberculosis and respiratory diseases. - 2011. -. № 5 - 6 - P.23 - 25.
3. Zyuzya Yu, R., L. Lepekha et al. Tissue and cell responses in the lungs of drug-resistant TB. / / Problems of Tuberculosis and Lung Disease. - 2004. - № 8. - C -53 - 57.
4. Global tuberculosis control 2011. Geneva: World Health Organization; 2011 (WH0/HTM/TB/2011.16).
5. Infuso A., Falzon D. European superveillance of tuberculosis: description of the network and recent resalts / / Med. Mai. Infect. - 2005. - Vol.35, P. - 264 - 268.
Pregravid preparation women with dysfunction of hypothalamus
ZkukovetsI.V.
Amur State Medical Academy,Blagoveshchensk, Russia
Abstracts. Violation of fertility was diagnosed in 40% of women with hypothalamic dysfunction (DG). Mutations both appear functional activity of the ovary and endometrium. Based
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on the research level of progesterone, glikodelina and blood flow in the basal and spiral arteries of the uterus developed pregravid preparation options. The most effective, pathogenetically substantiated, a variant of a comprehensive training with progestogens.
Key wordsrhypothalamic dysfunction, endometrium, progestogens.
DG is a neuroendocrine disorder with a pronounced polymorphism of clinical manifestations and is one of the first places among the causes of reproductive disorders in childbearing age leads to infertility in 40.0% of women [1,2,4,6]. Impairment of fertility is associated with dysfunction of the hypothalamic-pituitary axis and the lack of incentive effects on the ovaries [5,7]. The onset of self pregnancy can not be excluded at this stage in the absence of correction pregravidal training leads to increased complications of pregnancy and childbirth [3,9] Comprehensive Assessment and rehabilitation of women with DG with the hormonal and metabolic disorders, as well as the effect on the functional activity of the ovary and endometrium will identify the most effective steps pregravidal training.The purpose of the study is to develop a rehabilitation phases, depending on the hormonal and metabolic disorders and options pregravidal training with the functional state of the ovary and endometrium.
Materialsandmethods
Our study included 90 women with DG who will conceive - the main group. The study group included women with DG, whose pregnancy was the result of the treatment, rehabilitation and pregravidal training, puberty (n = 38) and women who corrected violations specific to DG was carried out only in the reproductive age, in fact the messages on the infertility (n = 52). Comparison group consisted of women without endocrine disease (n = 40). Progesterone (Pr) was investigated in venous blood serum using ELISA kit "SteroydIFA-Pr-01" on day 21 of the menstrual cycle (MC). Contents glikodelina determined menstrual blood serum on day 3 MP cycle using ELISA test kits -BioservGlicodelin-Elisa to quantify protein. Sonography and color Doppler mapping Doppler velocimetry in the basal and spiral arteries were performed on a stationary machine «ACCUVIX -XQ» (Korea), transvaginal, with a frequency of 9 MHz transducer, with the calculation of systolic and diastolic ratio (SDO) and resistance index (IR).
Resultsanddiscussion
The core group and the comparison group were matched for age (24,99 ± 3,44; 26,51 ± 4,34 years, p> 0.05). BMI in women with DG was 31,23 ± 0,84 kg/m2, which was significantly higher than in the comparison group - 21,7 ± 0,41 kg/m2 (p <0.001), given the lack of correction of metabolic disorders before entry in a study in 52 women.
In the study group diagnosed earlier onset of menarche -11,08 ± 0,13 years, 41 (45.6%) women were impaired menstrual function. In women who have applied for infertility, often at the expense of polimenorei in 18, oligomenorrhea and amenorrhea, which were equally common in 8 surveyed. Women corrected with puberty only found in 7 oligomenorrhoea surveyed.
56 (62.2%) women are the main group appealed for infertility, 4 of them have been corrected at puberty, pregnancy was missing from 2 to 6 years. Primary sterility occurred in 12 (21.4%), secondary in 40 (71.4%) of the subjects. The high frequency of secondary infertility due to a history of 19 women have abortions, in 11 genera in 6 failed and in 4 of spontaneous abortion.
During the test in 52 women with infertility, gynecological pathology revealed the following: subserous uterine fibroids type 0 in 5, subserous uterine fibroids type 1 in 3, submucous fibroids type 0 in 1, endometriosis, ovarian 1 -2 degrees at 4, dermoid ovarian cyst at 3. According to a survey conducted laparoscopy 30 (57.7%) women. Hysteroscopy with endometrial biopsy for 25-26 day MC held 52 women surveyed. One of them with a resectoscope in volume removesubmucous node type 0. Histological study of endometrium in 11 women revealed endometrial hyperplasia without atypia, 19 endometrium corresponded to the proliferation stage, in the early 22 secretion. Four women who applied for infertility, corrected with puberty, as well hysteroscopy performed in two cases by histology endometrium corresponded early in two late-stage secretion
Impaired glucose tolerance was found in 14 (26.9%), insulin resistance (IR) in 17 (18.9%) of 52 women from the main group, who turned in the reproductive age for infertility. In 1 (2.6%) of 38 women with correctable puberty diagnosed with TS and in the reproductive age (j = 3,997, p <0.001). Of the 38 girls reaching reproductive age in 11 diagnosed and corrected by TS at puberty. With IR and abdominal obesity were impaired lipid metabolism by increasing the levels of LDL cholesterol, lower HDL cholesterol. Gipalfaholisterinemiya observed in every 4 women are the main group - 23 (25.6%). Disorders of carbohydrate and lipid metabolism lead to a change in the sensitivity of receptor system in the hypothalamus and in the ovary, accompanied by anovulation and hyperandrogenism [5,7].
Content Ex 21 days MC was 30,39 ± 2,8 pmol / L in the control group is 1.8 times higher -56,13 ± 2,61 pmol / l (p <0.01). These changes are associated with the violation of folliculogenesis and anovulation, due to the persistence of the subsequent follicular atresia [4,6,9]. Endometrial hyperplasia at 11 and myometrium in 9 women linked apparently lack of anti proliferative effect Pr and extragonadal elaboration estrone adipose tissue. The level Pr women with modifiable puberty was 46,54 ± 4,61 pmol / l and had no differences in the comparison group (P> 0.05) in contrast to women who are exposed to DW reproductive period, wherein the OR was 18,24 ± 1,73 pmol / l (p <0.001).
According to the M-echo ultrasound endometrium on day 21 of MC differed from a comparison group and was 10,11 ± 1,41 mm and 12,47 ± 0,98 mm (p> 0.05). In this case, 90 of the surveyed women in 9 (10.0%) M-echo was more than 14 mm (14,38 ± 3,73 mm) in 20 (22.2%) did not meet the second phase of the MC - 7,12 ± 1.93 mm, which is determined in a subsequent holding of hysteroscopy and endometrial biopsy sighting. The changes were characteristic of the 36 (69.2%) of 52 women who exhibited the DW in the reproductive age, and 2 (5.3%) of the 38 corrected at puberty (j = 7,029, p <0.001).0varian volume in the study group was 12,96 ± 1,61 mm in the control group 2 times less - 6,21 ± 1,13 mm (p <0.05). In the study group corpus luteum was visualized only in 32 (35.6%), 29 of them corrected with puberty and reproductive 3. The total number of follicles was 9,2 ± 2,4 units, ranging in size from 3 to 7 mm (5,26 ± 0,18 mm), more than 10 follicles in the slice was recorded in 18 women, which indicated that multifollikulyarnoy transformation. These changes were observed in the ovaries of women who are diagnosed with DG exhibited in the reproductive age.
The study of blood flow in the basal and spiral arteries of the uterus on day 25 -26 MC allowed to visualize the spiral arteries in only 59 (65.6%) of the subjects of the main group. IR and SDO in the basal arteries of the uterus characterized by reduced blood flow to $ 0,43 ± 0,02 and 2,18 ± 0,23, in the comparison group 0,36 ± 0,01 (p <0.05) and 1,43 ± 0.11 (p <0.01). Women corrected with puberty IR and SDO in the spiral arteries of the uterus were 0,39 ± 0,02 and 1,48 ± 0,08 respectively, figures were not different from the comparison group (p> 0.05). In women, the diagnosis of which DG exhibited in the reproductive period the comparable figure was 0,41 ± 0,02 and 1,61 ± 0,11, relative to the comparison group had opposed SDO (p <0,05), IR (p> 0.05 ) resulting in a violation of the blood flow in the endometrium. The latter may be due to low levels of Pr (r = -0,69, p<0.05) and lower index TS Saro F. (r = -0,54, p<0.05), atherogenic lipid profile changes in blood - increasing LDL (r = 0,69, p <0.05), which can lead to disturbance and functional activity of trophic endometrium.
The content glikodelina women core group was 9,14 ± 1,17 ng / ml, which was 2 times lower than in the comparison group - 19,29 ± 1,23 ng / ml (p <0.05). In 38 women with a corrected age of puberty glikodelin was 15,31 ± 2,82 ng / ml and did not have differences from the comparison group (p> 0.05). In 52 women who were exposed to the DW in the reproductive age glikodelin was lower than in the comparison group - 5,34 ± 1,31 ng / ml (p <0.01). Low glikodelina correlated with decreased Pr (r = 0,74; p <0.001), and blood flow (SDO) of spiral arteries in the uterus (r = -0,58; p <0.01). Which leads to inadequate secretion phase, or lack of [2,8,9]. In our study, 41 (78.8%) of the 52 surveyed infertile women of reproductive age.
Conclusions
It can be concluded that the timely correction of violations with puberty results in a less pronounced changes in the reproductive age. Requires a much lower cost saves a favorable prognosis for pregnancy through an adequate level of Pr, gikodelina and blood flow in the basal and spiral arteries of the uterus.In the reproductive age in two stages with the rehabilitation of the main gynecological disease and disorders of carbohydrate metabolism.
Stage 1 - hospital. In view of the identified gynecology surgery performed by laparoscopic access, detect endometrial pathology - hysteroscopy. Duration of hospital phase was determined by the primary gynecological pathology and ranged from 3 to 7 days.
Stage 2 - outpatient. Was the determining lifestyle modification.Increasing physical activity and dietary changes. Prescribed herbal medicine for lowering glucose levels, overcoming TS correction of lipid metabolism: plants containing biguanide - sash fruit peas, beans, sprouts and leaves of bilberry, plants containing zinc and chromium - the rhizome of ginger, laurel leaves, plants, reduce appetite, having the property of swelling and mucus to form in the gastrointestinal tract - algae, seaweed, flax seeds.Correction performed siofora TS 850 mg 2 times a day course of 6 months. Subsequent correction of hormonal therapy was carried out against the background of siofora or after 6 months of treatment in terms of the index Caro F.ne less than 0.33.
In order to reduce body weight, in the absence of R & D have been recommended anorectics with combined serotonergic and noradrenergic action - sibutramine (Meridia), a daily dose of 10 mg, in the course of 6 months. Or administered peripherally acting drugs that contributed to the suppression of the activity of gastrointestinal lipases and reduce the absorption of fat - Orlistat (Xenical) 120 mg 3 times a day with meals.
Hormonal correction was carried out taking into account the identified gynecological pathology. For the treatment of endometrial hyperplasia prescribed progestogens (Duphaston 20 mg) with a 14 to 25 day menstrual cycle, the course of 6 months or Lindinet -30 in prolonged mode 3 months. After conservative myomectomy or cystectomy for endometriodnyh Brush Recommended by Jeanine contraceptive scheme, course of 6 months. In two cases, the antagonists are administered gonadoliberinesBuserelin 3.75 mg 1 time in 28 days, the course of 3 months. Duration 2 stages from 6 to 18 months.Pregravid preparation was carried out after the hospital and out-patient treatment phase. Infection as a cause of infertility was excluded during hospital stay. Identified several options pregravidal training.
The first option - the abolition of combined oral contraceptives. With a view to the regulation of MTs or prevent pregnancy prescribed combined oral contraceptives with progestin component drospirenone (Yasmin, Jess). Drospirenone has antimineralokortikoidnoy activity, increases the excretion of Na and water, which can prevent the increase in blood pressure, weight gain, swelling, breast tenderness and other symptoms associated with fluid retention. Drospirenone has no effect on glucose tolerance and TS. COCs were appointed in the absence of IR. Planning for pregnancy after
2 MC after the abolition of contraception.The effectiveness of treatment 32.2% - 29 examinees.Mainly included women who were corrected with puberty.Duration of pregnancy from 3 to 9 months.
Indicators for which the scheme was effective: Pr - 41.93 - 51.15 pmol / L, glikodelin 12.49 -
18.13 ng / ml, the blood flow in the spiral arteries of the uterus - IR -0,37-0,39, SDO - 1.40 - 1.56.
The second option - COC for 3 - 6 months.Then the chimes on 1 (25 mg) tablet 3 times a day,
3 month course. At the 3 month appointed magnesium B6 2 tablets 4 times a day. The efficacy of this regimen was 14.4% - 13 examinees. Duration of pregnancy from 3 to 9 months. To prevent developmental abnormalities of the central nervous system of the fetus administered folic acid 400 ug / day.
Indicators for which the scheme was effective: Pr - 28.59 - 36.19 pmol / L, glikodelin 8.53 -
12.14 ng / ml, the blood flow in the spiral arteries of the uterus - IR - 0,38 - 0,44, SDO - 1.44 - 1.6.
Third embodiment - the second embodiment in conjunction with the reduction of the second
phase of the menstrual cycle with the use of progestogens (utrozhestan 200-300 mg) from 14 to 25 day menstrual cycle rate of 6 months. The dose was adjusted according to the basal body
temperature. The effectiveness of treatment 48.9% - 44 examinees.Duration of pregnancy from 3 to 6 months.
Indicators for which the scheme was effective: Pr - 16.51 - 19.97 pmol / L, glikodelin 4.03 -6.65 ng / ml, the blood flow in the spiral arteries of the uterus - IR - 0,39 - 0,43, SDO - 1.50 - 1.72.
4 (4.4%) women ovulation induction was carried out anti-oestrogenic drugs - clomiphene citrate was administered with an incremental increase in the daily dose of 50 mg in each subsequent cycle of up to 150-200 mg per day 5-9 of the menstrual cycle for 3-6 cycles.
The same way women with DG pregravid preparation should be carried out taking into account the functional activity of the ovaries and endometrium. The efficiency was expressed third embodiment, compared with the first (p = 2,294, p <0.05) and the second (p = 5,172, p <0.001).
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6. Ciechanowska M. et all. Effekt of stress on the expression of GnRH and GnRH-receptor (GnRH-R) genes in the preoptic area - hypothalamus and GnRH-R gene in the stalk/median eminence and anterior pituitary gland in ewes during follicular phase of the estrous cycle// ActaNeurobiol Exp. (Wars). - 2007.- Vol. 67. - №1 - P. 1-12.
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8. Jakubowicz D.J., Essah P.A., Seppala M. et al. Reduced serum glycodelin and insulinlike growth factor-binding protein in women with polycystic ovary syndrome during first trimester of pregnancy. // J. Clin. Endocrinol. Metab. - 2004. - Vol.89, №2. - P. 833839.
9. Kwintkiewicz J., Giudiece L.C. The interplay of insulin-like growth factors, gonadotropins, and endocrine disruptors in ovarian follicular development and function // Semin. Reprod. Med. - 2009. - Vol.27, №1. - P.43-51.
The analysis of conformity to standards chronic obstructive pulmonary disease's
treatment in the outpatient setting
ZhuravskayaN.S., ShakirovaO.V.
State Educational Institution of Higher Professional Education "Pacific State Medical University of the Ministry of Public Health Russian Federation",Russia, Vladivostok,Ostryakov Avenue, 2 tel. 8(423)2639675, E-mail: zhuravskaya187@gmail.com
Abstract
The goal of research is to study therapeutic and pulmonary doctor's perception about etiology, pathogenesis and therapeutic approach of chronic obstructive pulmonary disease, to estimate the
