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best results with the tumor-to-breast ratio more than 1/4-81,1% (p= = 0,249). (x2 = 2,53 the third degree of freedom p <0,05).
Thus, comparing the results of treatment of breast cancer based on the tumor size only, excluding the ratio of the tumor volume and the body is not completely correct. In this regard, the only rational approach to the forecasting of issues in any pathological conditions including breast cancer can be a comprehensive analysis of information about the patient, the disease pattern, using the available arsenal of reliable clinical features and diagnostic indicators.
Tumor-to-breast ratio has a statistically significant impact on the outcome of the treatment of breast cancer. It is necessary to conduct a more in-depth study to determine the criterion laws discovered by us, for a supplement to the classification of breast cancer.
The study shows the complexity of a clear and reliable prediction of disease outcome. We have tried to link the size of the tumor and breast volume on outcome. Many questions still await answers. In the future, they will no doubt be developed by us, further developed and refined. Finally, in one study it is impossible to specify all possible variants of the disease. But all these problems, obviously, can and should be the subject of separate research.
References:
1. Christakis N.A. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: University of Chicago Press; 1999.
2. Fletcher S.W., Fletcher R.H., Greganti M.A. Clinical research trends in general medical journals, 1946-1976. In: Roberts EB, Levy RI, Finkelstein SN, Moskowitz J, Sondik EJ, eds. Biomedical Innovation. Cambridge, M.A.: MIT Press; 1981.
3. Mackillop WJ., Quirt C.F. Measuring the accuracy ofprognostic judgments in oncology. J Clin Epidemiol 1997; 50: 21-29.
4. Kalbhen C. L., McGill J. J., Fendley P. M., et al. Mammographic determination of breast volume: comparing different methods. Am J Roentgenol 1999; 173: 1643-9.
Kuldashev Kahramon Abduhalilovich, The chair Traumotology, orthopedics, neurosurgery and The department of military field surgery candidate of medical science E-mail: kuldashev-23@mail.ru
Surgical treatment of secondary brain injury combined with cranial trauma
Abstract: Rresearch based on analysis of 315 patients, between 2011 and 2016, passed a comprehensive examination and treatment in the Andijan branch of the Republican Scientific Center for Emergency Medical Aid. In the study groups at all 315 (100%) patients with traumatic brain injury, including the spine and spinal cord injuries occurred in 88 (27.9%), extremity injuries — 123 (39%) injuries of the pelvis — 37 (11.7%), chest trauma occurred in 67 (21.2%) cases. Keywords: concomitant traumatic brain injury, secondary damage, surgical aspects.
Introduction
Combined injury as the most serious form of damage is characterized by high and has no tendency to decrease mortality of between 23,5-85%, and long-term disability, and a high level of disability (from 25 to 80%), exceeding 10 times that of when isolated lesions [1; 2].
According to many authors, the poor results of treatment of patients related to the lack of a unified doctrine of surgical relief of severe combined trauma and the treatment of the majority of those affected by the general surgical hospitals and surgeons with insufficient representation about the features of surgical tactics in combined injuries [3; 4]. Combined traumatic brain injury (SCHMT) — a kind of type of injury, in which the pathological changes in the body create serious difficulties in the diagnosis and treatment especially in the acute period [5].
To date, the treatment of victims in the acute period of severe SCHMT remains complex and urgent problem (Reilli P., 1997, Konovalov AN, et al., 2001). It was found that the highest value for mortality and disability of victims, along with the primary are secondary brain injury factors (voiti SG, ea1991; Bullok K. ea.1995; Chegrut RM ea, 1993; Gaytur EI, 2000).These include extracranial factors such as hypoxia, arterial, hypo — and — hypertension, hyperthermia, violation of gas exchange and internal homeostasis, as well as intracranial factors (intracranial hypertension, disturbance of cerebral circulation and metabolism), accompanying the acute
phase of severe head injury, aggravating his clinical course and directly influencing the prognosis and outcome (Kohy Y., ea1984; Lam AM, ea 1991; Miller JD 1993; Nakamura Nea 1993).
Objective
To determine the indications for surgical and conservative treatment of the secondary damage of combined traumatic brain injuries
Materials and Methods: Our study is based on an analysis of 315 patients, between 2011 and 2016, passed a comprehensive examination and treatment in the Andijan branch RSCEMH (Andijan Regional Emergency Medical Hospital).
In the study groups at all 315 (100%) patients with traumatic brain injury, including the spine and spinal cord injuries occurred in 88 (27.9%), extremity injuries — 123 (39%) injuries of the pelvis — 37 (11.7%), chest trauma occurred in 67 (21.2%) cases. Of the 315 victims of brain squeezing intracranial hematomas were in 158 (46%). In this analysis included only 101 patients who underwent complete dynamic MDCT study, since the first days after the injury. Statistical analysis was conducted using the basic clinical and MSCT and MRI data (volume of intracranial hematoma, brain swelling severity, prevalence of cerebral edema, the degree of displacement of the transparent partition). Patients were divided into three groups depending on the cause compression of the brain: the first group — 46 affected by compression of the brain intracerebral hematomas; the second group — 34 affected by compression of the brain enveloped hematomas, which were accompanied by
Surgical treatment of secondary brain injury combined with cranial trauma
structurally unstable parenchymal lesions; the third group — 21 affected by compression of the brain enveloped hematomas, which were accompanied by severe parenchymal lesions.
When intracerebral hematomas most often the cause of the injuries were blows to the head or head and ancident (one-third of the victims). The average age they were highest. The severity of their condition does not differ materially from the severity of the patients of the second group (t = l, 6; p> 0,05). The average amount ofbruis-ing, and a shift of midline structures were lowest in this group of patients.
The second group was characterized by the youngest age and the severity of the patients at admission. unconsciousness period was shorter. When we look at the causes of traumatic brain injury in this group could not be found, the prevalence of what — or mechanism of injury. The average volume of the shell hematoma was twice as much as the volume of intracerebral hematomas. The shift of midline structures more pronounced.
The third group was characterized by a more severe state of patients, the most common cause of traumatic brain injury in this group was hitting the car at a traffic accident (25%). In addition, the duration of unconsciousness was greatest in this type of cord compression. On the severity of injury in this group of patients showed a maximum and the total volume of intracranial hematomas, and accordingly the maximum displacement of midline structures.
Analysis of the level of consciousness of the dynamics of oppression, found that one-third of patients, unconsciousness occurred after the light period. Most often a light period was observed among patients with the second and the third group (42%). At the same time he was the most characteristic shell hematomas. Along with lucid intervals were separately analyzed the main neurological symptoms in all patients who have had a lucid interval, regardless of the etiology of brain compression.
Clinical and computed tomography revealed a comparison of the close relationship between the duration of coma and outcomes for all patients with brain compression (r = 0.6; p < 0.01). The outcomes in these patients was significantly correlated with the severity of the condition on admission (r = 0.5; p < 0.01), the volume of intracranial hematoma (r = 0.3; p < 0.05), the severity of brain swelling (r = 0, 4, p < 0.01), the degree of compression of the tank base (r = 0.3; p < 0.05), the degree of displacement of midline structures (r = = 0.2; p < 0.05.
In determining these same patterns of patients with lucid intervals strong correlation with the volume of the hematoma outcomes have been identified, the severity of cerebral edema, the degree of displacement of midline structures and the degree of compression of the tank base (p <0.05). In patients who have loss of consciousness immediately after the injury occurred, these correlations were mild and not significant (p> 0.05). This suggests that patients with a light gap, in which the primary injury was less severe, the further course of the disease depends on the development of secondary brain damaging factors — increase hematoma, cerebral edema and the rise accordingly brain gain offset.
Laws of cord compression in patients of different ages differ. Based on the correlation analysis revealed that outcomes in patients up to 40 years (n = 146) was significantly dependent on the amount of pinching the substrate (r = 0.3; p <0.01), the prevalence of cerebral edema (r = 0.5; p <0.01), the degree of compression of the ventricular system (r = 0.3; p <0.01) and a base tank (r = 0.3, p < <0.01). While the age of 40 years (n = 56), injury outcomes were
not correlated with these parameters. This suggests that in patients under 40 years, there are more stringent volume ratios in the cranial cavity, the violation of which due to the additional volume and compression of the brain, have a more pronounced effect on injury outcomes (251).
The severity of the injury, which was assessed by the Glasgow Coma Scale on admission, provided a significant impact on the outcome. Outcomes in patients admitted to soporous or coma (n = =124) were associated only with the severity of concomitant brain edema (r = 0,3; p <0.01). Outcomes in patients admitted to the stunning (n = 72) were correlated with the volume of intracranial hematoma (r = 0,3; p <0.01) and severity of cerebral edema (r = 0,3; p <0.01). Therefore, patients in stunning most important prognostic significance hematoma volume and the associated cerebral edema.
Between the duration of coma and outcomes for all patients revealed a high degree of correlation. In patients with coma lasting up to 3 days inclusive (n = 120) outcomes injury correlated with the volume of intracranial hematomas (r = 0,2; p < 0.05), the prevalence of cerebral edema (r = 0,3; p < 0.01). In patients with coma lasting more than 3 days (n = 76) outcomes were correlated only with the prevalence of concomitant brain edema (r = 0,3; p < 0.01).
The prevalence of cerebral edema was significantly correlated with the outcome of the whole group. In the propagation of edema or within one lobe (n = 122) outcomes were closely linked with the volume of intracranial education (r = 0,2; p <0.05). In the case of the spread of edema on one hemisphere or its generalization (n= = 74) there was no correlation between computed tomography and performance outcomes. Therefore, when distributing edema of the brain or within the brain volume fraction of intracranial hematomas affects outcomes, but in the case of generalization cerebral edema, hematoma volume, the degree of compression of the ventricular system and tank base does not affect the outcome of the injury.
Results: Analysis of the unconscious depths of the dynamics among operate on and non-operated patients showed that the non-operated patients in the level of consciousness have been relatively stable for the first 11 days after trauma, while patients who were operated REMARC often showed clinical deterioration associated mainly with inhibition of the level of consciousness, and sometimes, and the growth of urological focal deficiency. When the amount of less than 30 ml, all patients were treated conservatively, and only surgical treatment was carried out with volume over 40 ml.
In case of focus contusion volume from 30 ml to 40 uses as surgical and conservative treatment. 9 patients with volume over 30 ml, which were not surgical treat, died three patients: one patient died as a result of not delete intracerebral hematoma, and the rest of the extracranial reasons.
Conclusions:
1. The conditional boundary between the amount of injury-crushing chamber in surgical and surgical groups can be carried out at the level of 30 ml.
2. If there is a penetrating head injury or depressed surgical treatment is definitely indicated, even if the person meets the above criteria.
3. The choice of method of treatment of patients with focal injuries crushing 3-4 types based on clinical indicators and MSCT. The success of treatment and the right choice of tactics in this time is not possible without taking into account the secondary intracranial and extracranial factors and their severity, and without taking into account the proportion of focal and diffuse brain damage.
References:
1. Ropper A., Gress D., Diringer M., Green D. M., Mayer S. A., Bleck T. P. Neurological and Neurosurgical Intensive Care. Fourth Edition. LWW. - 2004. - P. 12-25.
2. Silver F. L., Norris J. W., Lewis A. J., Hachinski V.C Early mortality following stroke: a prospective review//Stroke.
3. Hlunovsky A. N., Starchenko A. A., Damaged brain. Methodological bases. SPb., - 1999.
4. Petrikov S. S., Krylov V. V. brain edema in surgery (clinic, diagnostics, treatment)//Cardiovascular disease. Application. Bull. NTSSSH them. AN Bakuleva RAMS. - 2008. - T. 9, number 6.
5. Romodanov AP Progressive consequences of head injuries//Questions of Neurosurgery. N. N. Burdenko. 1986. number 1.
6. Andrews B. T., Chiles B. W. 3rd, Olsen W. L., Pitts L. H. The effect of intracerebral hematoma location on the risk of brain-stem compression and on clinical outcome//J. Neurosurg. - 1988.
7. Adelson P. D., Bratton S. L., Carney N. A. et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents.
Khera Akshey, Tashkent, Ophthalmological Clinic "Vedanta", Ophthalmologist E-mail: retinauz@gmail.com Arnopolskaya Dina Iosifovna, Tashkent Cardiologist, Mirrakhimova Saidakhon Shukhratovna, Tashkent Medical Academy Department of eye diseases, PhD, Associate Professor, E-mail: saidakhon.m@mail.ru
Development of ocular hypertension in the eyes with proliferative diabetic retinopathy after vitreoretinal interference
Abstract: The factors of risk of occurrence of ocular hypertension in the eyes with proliferative diabetic retinopathy after vitreo-retinal surgical interference were studied.
The factors of risk of the increase of intra-ocular pressure in the eyes with PDR, including during post-operation period, were: the absence of panretinal laser coagulation of retina at earlier stages of PDR and tamponade of vitreous cavity with silicon oil. The application of silicon oil was significantly associated with the absence of pre-operation laser coagulation of retina with diabetic nephropathy, decompensation of carbohydrate metabolism and complicated course of operation and post-operation period.
Keywords: proliferative diabetic retinopathy, ocular hypertension, silicon oil.
One of the PDR complications is the increase of intra-ocular pressure, which is related to the iris neovascularisation (neovascular glaucoma) and development of intravitreal hemorrhages (ghost-cell glaucoma). After vitreo-retinal surgical interference, there is also a risk of ocular hypertension; tamponade of vitreous cavity is an additional factor of pathogenesis [1, 954-60].
The aim of the research was the study of factors of risk of occurrence of ocular hypertension in the eyes with proliferative diabetic retinopathy after vitreo-retinal surgical interference.
Materials and methods of research. The research included 160 patients (200 eyes) with diabetes complicated with grade IV diabetic retinopathy (proliferative diabetic retinopathy — PDR) admitted for surgical treatment at the clinic of eye microsurgery LLC «KuzTibServis» (Tashkent) and Eye center in Samarkand. All patients were divided into two clinical groups depending on the preceding laser coagulation: the PLC+ group included 116 eyes, on which laser photocoagulation was performed at grade III and early IV of PDR; the group PLC- included 84 eyes without preceding laser coagulation. The indications for operative treatment were: intravitreal hemorrhages that did not resolve within 3-6 months
without traction retinal detachment (within 4-6 weeks in case of grade I diabetes or bilateral damage); traction retinal detachment; progressing neovascularization despite pan-retinal laser photocoagulation, massive pre-macular hemorrhage, macula detachment, pre-macular fibrosis, combined retinal detachment, media opacity (including cataract, opacity of posterior capsular, vitreous opacity making laser photocoagulation difficult, neovascularization of iris, anterior hyaloid proliferation, macular edema resistant to laser photocoagulation). All patients included in the research underwent vitreal surgical interference. At the decompensation of IOP, fixed combined anti-hypertensive agent Brimoptic (brimonidine + thymolol) was used to reduce intra-ocular pressure.
Complete ophthalmological examination was performed during primary consultation of the patients on 1, 3 and 10 days post operation. Long-term results were evaluated after 3, 6, 9 and 12 months. The examination included the determination of the sharpness ofvision, IOP, conditions of anterior chamber, lens, posterior chamber and retina.
Results of the research and discussion. In the present research, in the PLC- group, 18 patients (21,43%) had increased IOP
