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threat for the occurrence of nosocomial diseases directly to the children's hospital.
In the course of the rehabilitation of patients with pneumonia of children along with the use of drugs, use non-drug remedies and treatments. It should be noted that non-drug program is still insufficiently used in pediatrics and the need for their propagation in the medical practice is evident.
Material and methods. We conducted a survey of115 healthy and sick children with pneumonia received in-patient treatment CCCH number 1 in Tashkent. 34.8 % of sick children came to the hospital in serious condition medium, while 36.5 % received diagnosed with severe pneumonia. In 45 % of the surveyed children combined with the basic pathology of infectious processes: catarrhal omphalitis, trombovaskulit of umbilical vessels, the phenomenon of acute respiratory viral infection, conjunctivitis, catarrhal otitis media, while 55 % found concomitant pathology of the central nervous system.
Observed the children were divided into 3 groups.
The control group consisted of 18 healthy newborns; comparison group — from 45 infants with pneumonia who received conventional basic therapy according to current guidelines and standards, and the main group — 48 infants with pneumonia who received conventional therapy in combination with low-intensity laser radiation.
We used the "Vostok" laser therapeutic device for scientific research. Laser therapy was carried out according to the developed scheme taking into account the existing recommendations.
Results of investigation and discussion. In 94 % of the children surveyed had acute onset pneumonia, clinically manifested wet cough (80 %), symptoms of intoxication (95 %).
Availability febrile fever during the early days of the disease was noted in 80 % of cases. In 20 % of cases occurring with normother-mia. In 30 % of cases the disease was preceded by ARVI. Typical local the physical changes in the lungs were detected only in 30 % of cases. The remaining children were heard hard breathing, diffuse variegated wheezing. Tachypnea noted in 31 %, tachycardia — in 48 % of cases. In 15 % of cases limited cyanosis of the skin in the nasolabial triangle it was expressed. In 10 % of patients revealed mild hepatomegaly. Hemogram at first days of the disease characterized by leukocytosis and a shift in blood counts in 16 % of cases.
All infants had radiographic evidence of pneumonia. In 86.6 % of the changes in lung tissue had a focal, in others — the drain — focal character. Most often observed localization of bilateral pneumonic changes (66.6 %). Most children diagnosed burdened premorbid background (71.6 %). Among the background conditions prevailed secondary immunodeficiency states (14 %), perinatal pathology of the central nervous system (27.7 %).
Laser therapy in children with pneumonia was used with 2-3 day hospital stay, during the reduction of symptoms of intoxication and to reduce body temperature. By the end of LT 80 % disappeared infiltrative changes in the lungs, improved clinical and laboratory findings (reduced or completely disappeared wheezing, hemogram indicators have stabilized — with the normalization of ESR and positive dynamics of leukocyte). All patients were well tolerated.
Conclusion
The effectiveness of laser therapy is expressed in the improvement of blood circulation, normalization of impaired circulation, activation of metabolic processes in the outbreak, reducing tissue edema, prevention of acidosis and hypoxia, a direct impact on the microbial factor and activation of the immune system.
References:
1. Алимухамедов А. Б., Крылов В. И., Касымов А. К. Влияние эндоваскулярного лазерного облучения крови на показатели метаболизма циклических нуклеотидов у детей грудного возраста с тяжелыми формами пневмоний//Педиатрия. - 1992. -№ 10-12. - С. 46-49.
2. Аль-Згул Л. Б. Немедикаментозные методы в комплексной реабилитации новорожденных детей: Автореф. дис. ... канд. мед. наук. - М., 1995. - 24 с.
3. Багиров М. А. Использование излучения полупроводникового лазера в комплексной предоперационной подготовке и в послеоперационном лечении больных туберкулезом легких: Автореф. дис. ... канд. мед. наук. - М., 2003. - 25 с.
4. Вечеркин В. А., Пахомова В. В., Королев П. В. Применение лазеротерапии в раннем восстановительном периоде у детей с острыми нагноительными заболеваниями легких и плевры//Тезисы докладов Респ. науч.- практ. конф. «Актуальные проблемы лазерной терапии». - Воронеж, 2008. - С. 39.
Umarov Odiljon Mahmudovich, Ferghana branch of the Republican Scientific Center of Emergency Medicine, Director E-mail: rizaev@rambler.ru
Surgical tactics in combined injuries of the bones of facial skull according to retrospective array
Abstract: The results of treatment of 3911 patients with combined injuries of the bones of facial skull were analyzed in the article. The issues of treatment of associated injuries, its surgical tactics take an important place among the urgent problems of modern surgery. The analysis has shown that variety of osteosynthesis classifications by time of performance, and contraversion data on immediate outcomes result to inconsistency of purely temporal approach in determining the treatment strategy for combined fractures of maxillofacial region, and necessity to develop new criteria and standards for selection of time, method and amount of traumatologic treatment.
Keywords: Combined maxillofacial trauma, surgical tactics, treatment criteria, ostheosynthesis.
Surgical tactics in combined injuries of the bones of facial skull according to retrospective array
The problem of treatment of associated injuries has an important place among the urgent problems of modern surgery, traumatology, maxillofacial surgery, neurosurgery and other surgical disciplines. This can be attributed to difficulties in diagnosis and treatment of this category of victims, a high percentage of deaths and the poor results of treatment [4; 5].
In recent years the frequency of injuries caused by the rapid development of industry, construction, transport, highlighting the social and economic importance of the problem increased significantly [2; 6; 7].
In the treatment of combined injuries of the middle zone of the facial skull there are three main problems in the foreground: the timing of specialized care, the amount of surgical intervention and the method of fixation of bone fragments.
Selection of optimal terms of osteosynthesis is an important issue in clinic of combined maxillofacial fractures. This position is confirmed by a variety of osteosynthesis classifications by time of performance [2; 5].
Materials and methods of investigation
In accordance with the aims and objectives of the present study we conducted a complete retrospective analysis of treatment outcomes of 3911 patients treated in Republican Scientific Center of Emergency Medicine for the past years 2001-2010. Archival materials with associated trauma of maxillofacial region were copied. "In-patient card" (F. № -003/y) was used as initial control material.
Striving for early osteosynthesis of maxillofacial bones, earliest activation of victims and prevention of complications, the indication and timing of operational intervention were estimated by different methods.
It allowed us to form two groups of surveyed victims and to carry a comparative analysis of peculiarities of traumatic disease (TD) duration, and closest treatment outcomes depending on the treatment strategy.
The first group of retrospective study included 2606 patients with combined trauma (CT) of maxillofacial region (MFR), treated at RSCEM from 2001 to 2007 (ARA — an array of retrospective analysis).
Indications and timing of osteosynthesis of maxillofacial bones in this group, with minimal risk to the patient, were established according to traditional separation of severity of the patient's condition and the severity of injuries.
The second group included 1305 clinical observations of the victims with combined injuries of MFR was treated at RSCEM from 2008 to 2010. In this group the possibilities to optimize surgical treatment of fractures were explored by using methods of objective estimation of the severity of injury (ACO — an array of clinical observation).
This article covers the issues of treatment tactics (time of specialized care, the amount of surgical intervention) in combined maxillofacial trauma according to the study of retrospective array.
Results of investigation and discussion
From 2003 to 2007, 652 victims were carried out 782 operations of osteosynthesis, that is, one victim had 1.2 osteosynthesis. Prevalence of fractures of the upper jaw in the general structure of maxillofacial fractures, determines a high proportion of intraos-teal osteosyntesis method by Malyshev applied in 61.8 % of cases. Extrafocal osteosynthesis with Ya. M. Zbarzha, V. F. Rudko's apparatus or Kirschner-wire (K-wire) by M. A. Makienko's method were used in 32.2 % of the victims, mostly with fractures of the lower jaw, in 6.0 % of cases a combination of osteosynthesis methods was used.
Average period of osteosynthesis in a retrospective array was 8.2 ± 0.7 days. We used accepted periodization of TD in selecting a group of victims, depending on the timing of osteosynthesis (Gu-manenko E., 1992).
The first group consisted of 122 patients (18.8 %) who got osteosynthesis on admission to the hospital, that is, in the first period of TD, characterized by acute disorders of vital functions. The second group was presented out of 125 patients (19.2 %), who had osteosynthesis on 2-3rd day, after relative stabilization ofvital functions, constitutes the essence of the second period of TD.
During the period of maximal probability of complications, extending from 4 to 10 days and corresponding to the third period of TD, 255 patients (39.1 %) were operated, composing the third group.
Another 150 victims (22.9 %) carried osteosynthesis operation on the forth period of TD, characterized by a complete stabilization ofvital functions, beginning with the 11th day after the injury. As seen from the data, the largest group of victims was operated on 4th day after injury - 62.0 %. Analysis of the dependence of the timing of os-teosynthesis and leading localization of damage is shown in Table 1.
As follows from the table 1, osteosynthesis timing varied depending on location of the dominant damage.
So osteosynthesis is most commonly performed when the brain injury was the leading component of CT, while in the group of victims who carried osteosynthesis within 10-days, abdominal and pelvic injuries were dominated. On 2-3-4 days osteosynthesis is carried mainly to patients with dominant damage of maxillofacial region, that is, patients with multiple fractures of the maxillofacial region (42.5 %), where fractures of both jaws only were 12.5 %. Thus, while the role of damage maxillofacial region as a leading component of the CT decreases and severity of injuries of the abdominal organs and extremities injuries increases, declination of surgical activity against the fractures of maxillofacial area is observed. The analysis of dynamics of victims' condition severity during the process of treatment is presented in Table 2.
Table 1. - Localization of dominant injury in patients with combined trauma of maxillofacial region depending on the timing of osteosynthesis ( %)
Localisation of dominant injury Time of maxillofacial bones osteosynthesis' performance Total
On admission 2-3 days 4-10 says Later than 10 days
Head (face) 14.7 10.5 12.3 7.8 15.8
Neck 2.3 0.0 1.2 0.0 1.2
Chest 7.9 5.0 7.7 8.7 7.6
Abdomen 2.6 2.5 5.1 19.6 7.8
Pelvis 2.6 2.5 10.3 17.4 9.3
Spine 1.2 0.0 1.3 4.3 1.6
Extremities 51.1 67.0 42.9 25.0 50.6
Combined 1.8 0.0 5.1 6.5 6.1
Total: 18.8 19.2 39.1 22.9 100.0
Table 2. - The dynamics of the general condition of the victims
Severity of the victims condition On admission By the end of1st day By the end of 3rd day By the end of 6th day
Abs. % Abs. % Abs. % Abs. %
Satisfactory 0.0 0.0 21 0.8 190 7.3 571 21.9*
Moderate 477 18.3 1256 48.2* 1535 58.9* 1514 58.1*
Severe 1816 6937 1227 47.1* 844 32.4* 466 17.9*
Very severe 297 11.4 96 3.7* 13 0.5* 36 1.4*
Terminal 16 0.6 6 0.2 24 0.9 19 0.7
Total: 2606 100.0 2606 100.0 2606 100.0 2606 100.0
Note: * — statistically significant difference compared with the state on patients' admission (p < 0.05).
From the table we see that on admission to the hospital, most of them (69.7 %) were in the severe and very severe (11.4 %) state, the leading causes of choice were life-threatening consequences of injuries and traumatic shock (TSH). Intensive care was requested in 96.4 % cases, surgical intervention — in 54 % of the total number ofvictims.
Amount of emergency operations, performed on admission to the hospital, was 42.8 %, urgent operations — 17.9 %, deferred operations - 16.2 % and 23.1 % of planned operations. Although 61.9 % of patients improved their state by the end of 1st day, positive trend mainly was supported by increasing in the number of victims in a moderate state up to 2.5 times, accompanied with extremely small number ofvictims in satisfactory condition (0.8 %). This suggests that achievement ofmoderate severity state by the end of the first day in patients with CT should be considered as a success of pursued intensive care.
Reducing the rate of positive dynamics in victims condition in the next two days is explained by, first of all, the preservation of effects of life-threatening factors of trauma, and the second — with the development of complications.
The victims in moderate severity condition virtually remained the same 58.1 % by the end of six days, satisfactory condition at that
In the group of patients with very severe condition the incidence of complications was 100 %, and mortality from them — 50.0 %. Such a big difference in terms of mortality in groups of victims who were in a state of moderate and severe conditions on the day of operations (4.0 % and 24.8 %, respectively), with equal frequency of complicated cases with favorable outcome of TD's duration (24.8 % and 21.8 %, respectively), may indicate the inadequacy subjective estimation ofvictims condition.
Surviving victims' average period of hospitalization was 53.2 ± 3.2 days. In half of the cases it has not exceeded 1.5 months, and 12 % of the patients' hospitalization lasted more than 3 months. Only 4.5 % of victims did not require treatment in the intensive care unit, and the rest of the victims treated in this department 6.9 ± 0.4 days in average. While in 33.7 % of the cases, the duration of treatment should not exceed 3 days, in 23.8 % — six, and in 24.2 % — ten days. Thus, the treatment tactics in combined maxillofacial trauma, according
time was observed in 21.9 %, and severe conditions decreased from 69.7 % to 17.9 %. During this period, among the causes of victims' serious condition, the role of late complications, including pneumonia increases, because life-threatening effects of trauma, in most cases, have already been eliminated, or resulted in death.
On the other hand, analysis of the severity on the day osteosynthesis was performed, showed that most of the victims at the day of osteosynthesis was in a state of moderate (42.6 %) and severe conditions (46.7 %). 7.9 % was in satisfactory condition and 2.8 % — in critical. Table 3 shows the dependence of types of TD clinical duration upon the severity on the day of osteosynthesis.
From the data presented in this table, we can see that osteosynthesis performed in victims in satisfactory condition does not result in a subsequent fatal outcome and associated with low complication rate (7.6 %). In the group of victims of moderate severity on the day of osteosynthesis the rate of complications was 47.7 %; and 4.2 % of complications were the cause of death. Group of victims in severe condition on the day of osteosynthesis, characterized by a higher rate of complications (41.9 %), and in 5.8 % of cases complications were cause of death.
to a retrospective array, were based, on the one hand, on striving for an early performance of osteosynthesis, and on the other hand on a subjective estimation of the severity of patients' condition, allowing operation without the threat of complications and death. High variability of damage combinations ofvarious regions of the body in CT, the processes of their mutual aggravation substantially restricted rational treatment strategy choices in combined MFT.
On the other hand, the subjective method of severity estimation in retrospective leaded to inadequate surgical tactics: over-estimation of organism's reserves led to undue mortality, underestimation — to the loss of optimal terms for osteosynthesis due to complications development aggravating condition of the victims and postponing the time of this surgery on indefinite time. As a result, the average term for osteosynthesis to be performed was 8.2 ± 0.7 days, with 38.6 % of patients underwent surgery during the period from 4 to 10 per day, that is the most likely period
Table 3. - The dependence of the clinical duration of TD upon the severity of the victims on the day of maxillofacial region bones osteosynthesis (n = 2 606)
Severity of condition Duration type Total
Not complicated Complicated
With favorable outcome With un favorable outcome
Abs. % Abs. % Abs. % Abs. %
Satisfactory 96 3.7 8 0.3 0 0.0 104 4.0
Moderate 446 17.1 175 6.7 26 1.0 647 24.8
Severe 297 11.4 156 6.0 115 4.4 568 21.8
Very severe 0 0.0 18 0.7 18 0.7 36 1.4
Total: 839 32.2 357 13.7 159 6.1 1 355 52.0
Our experience of thoracoscopy application in diagnostics of pleuritis of unclear etiology
for complications to occur. The severity of victims' condition was not determined so much by damage to maxillofacial region as damage to other areas of the body. Implementation of osteosynthesis on admission and during the first 24 hours in 16.8 % of the victims identified the leading component of CT as damage of the brain, and in the group of victims who carried osteosynthesis within 10-days, abdomen and pelvis injuries prevailed. The highest frequency of multiple fractures of MFR (20.0 %) of which only fractures of both jaws were 12.5 %, resulted in a priority of the head as a leading component of CT in victims — those patients carried osteosynthesis mainly on 2-3rd day.
Type of osteosynthesis was determined by localization and nature of MFR fractures. Prevalence of the upper jaw fractures in
the overall proportion of fractures determined a high proportion of intraosteal osteosynthesis applied in 69.8 % of cases. Extrafocal osteosynthesis with V. F. Rudko or Y. M. Zbarzha's apparatus used in 41 patients (20.3 %), mainly with the fractures of the lower jaw.
Surviving victims' average term of hospitalization was 53.2 ± 3.2 days. 95.5 % of victims needed intensive care, and its duration was 6.9-6.4 days in average.
Thus, the variety of osteosynthesis classifications by time of performance, and contradictory data on immediate outcomes, depending on this factor shows inconsistency of purely temporal approach in determining the treatment strategy for combined fractures of maxillofacial region, and necessity to develop new criteria for selection of time, method and amount of traumatologic treatment.
References:
1. Vernadsky Y. I. Traumatology and Reconstructive Surgery Cranio-Maxillo-facial region. - Moscow: Medical Literature, 1999. - 456 p.
2. Datsko A. A. The implementation of modern principles of treatment of injuries of the maxillofacial region//Dentistry. - 2003. -№ 1. - P. 17-22.
3. Lebedev V. V., Okhotskiy V. P., Kanshin N. N. Emergency aid for combined traumatic injuries. - M., 1980. - P. 82-107.
4. Mylnikova L. A. Medical and tactical aspects of medical care to victims of road accidents in the prehospital stage//Ambulance. -2001. - № 2. - S. 7-10.
5. Trunin D. A. Improving the system of care for patients with maxillofacial trauma. Actual issues in dentistrycal practice: Interregional Sat mes. Reports.and articles, dedicated to 35 - anniversary of the Dental Faculty. - Samara, 2001. - S. 124-126.
6. Boudrieau R. Miniplate reconstruction of severely comminuted maxillary fractures in two dogs//Vet. Surg. - 2004. - Vol. 33, № 2. - P. 154-163.
7. Califano L. Morbidity by planning in maxillofacial surgery//Minerva Stomatol. - 2002. - Vol. 51, № 6. - P. 241-245.
Usmanov Bekzod Baymatovich, doctor oncology, department of thoracic oncology; National Cancer Research Center, Republic of Uzbekistan E-mail: usmanov-83@mail.ru Khairutdinov Rafik Vakhidovich, MD, head of the department of thoracic oncology, National Cancer Research Center Yusupbekov Abrorbek Axmedjanovich, MD, deputy director of the National Cancer Research Center
Ismailova Umida Abdullaevna, Postgraduate-student, Department of General Oncology and Radiation Diagnosis, Tashkent Medical Academy
Our experience of thoracoscopy application in diagnostics of pleuritis of unclear etiology
Abstract: This study includes 45 patients with pleural exudate of unclear etiology who underwent diagnostic thoracoscopy (TS). Etiology of pleuritis of unclear etiology was rather diverse, however in 36 (80 %) patients, the cause of exudate accumulation were malignant tumors. Efficacy of thoracoscopy in the differential diagnosis of pleuritis of unclear etiology accounted 100 %. Because of miniinvasiveness thoracoscopy may be recommended as method of choice at this pathology. Keywords: thoracoscopy, exudative pleuritis, methothelioma.
Introduction
Long before the Swedish doctor Hance Hristian Yakobeus the first thoracoscopy with binocular endoscope was performed by the Irish Richard Cruise in 11-year-girl with pleuro-thoracic fistula in 1866 [1]. In XX century this method was used predominantly for diagnosis and treatment of tuberculosis for decades. Now the thoracoscopy has been used both in the benign pathology and malignant neoplasms. The obvious advantages of such operations are as follows: small traumacity, good cosmetic effect, minimal frequency
of complications and fast rehabilitation of the patients. To the present time in the oncological clinic the main indications for thoracoscopy have been developed:
1) pleuritis of unclear etiology;
2) disseminated process in the lungs;
3) précising diagnosis of the pulmonary cancer;
4) lymphoadenopathy of the mediastinum;
5) benign peripheral pulmonary tumor;
6) solitary metastasis;
