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Aim. Study of diagnostic significance of serum level of tumor necrotizing factor a (TNF-a), C-reactive protein (C-RP) and procalcitonin (PCT) in infective endocarditis (IE).Methods. 66 patients with IE (60,6% male, 39,4% female), 35 with primary IE, 31 - with secondary IE, were included into the study. Clinical and laboratory investigation included determination of serum concentration of TNF-a, C-RP and PCT.Results. Dynamics of serum concentration of TNF-a, C-RP and PCT were described, types of changes of this parameters, which showed an unfavorable prognosis of infective endocarditis, were distinguished.Conclusion. Determination of serum level of TNF-a, C-RP and PCT can be used for description of the disease severity.

Introduction. Chronic recurrent instability of the shoulder joint is a frequent outcome of conservative treatment oftraumatic dislocation of the shoulder (2.8–30 % of cases). Preoperative examination largely determines the outcome of surgical treatment of this pathology.The aim of the study was to provide a clinical assessment of the developed algorithm for the surgical treatment of patients with recurrent anterior shoulder joint instability. Materials and methods. The results of treatment of 98 patients with recurrent anterior shoulder joint instability were studied. Preoperative examination included clinical tests, MRI or CT with calculation of bone loss. Fifty-six patients (57.1 %) underwent Bankart operation, 14 patients (14.3 %) – Latarjet operation. Twenty-three patients (23.5 %) underwent Bankart + Remplissage surgery, and 5 (5.1 %) – Latarjet + remplissage. The result was assessed on the ROWE scale.Results. Bone defects significant in the formation of instability (“glenoid off track”) were found in 19.4 % of patients, and “glenoid on track” – in 80.6 %. According to the proposed algorithm for treating patients with anterior recurrent instability of the shoulder joint, the “glenoid off track” state was an indication for Latarjet surgery. When “glenoid on track” was used, indications for Bankart operation were displayed. The remplissage procedure was indicated in case of the presence of a Hill-Sachs grade 3 defect or the presence of hyperelasticity of the tissues of the shoulder joint. The mean ROWE score for the entire group of patients before surgery was 41.5 ± 12.8 points, and 15 months after sur gery – 94.9 ± 3.4 points. Two recurrent dislocations were revealed, one of which was associated with repeated trauma, and the other – with an incorrect choice of stabilization technique. One complication (axillary nerve neuropathy) was observed, which was arrested conservatively.Conclusions. The proposed algorithm allowed us to obtain positive results in 97.9 % of cases.

Purpose. To study the effect of hyperbaric oxygenation (HBO) on the oxygen regime and ammonia metabolism in the neurons of cat cortex in hemorrhagic shock.Material and methods. Experiments were performed on 164 cats (males). The effect of HBO (3 ATA, 50 min) on cerebral blood flow (CBF), oxygen tension (PO2), the content of ammonia (Am), glutamine (Gn), glutamate (Gt), α-ketglutarate (α-KG), the activity of glutamate dehydrogenase (GDG), glutamine synthetase (GS), phosphate-dependent glutaminase (PDG) activity was studied in the sensorimotor cortex (SMC); the content of Am, GN and oxygen parameters in arterial (AB) blood and venous blood (VB) of the sagittal sinus in hemorrhagic shock caused by fractional bloodletting of their femoral artery at a rate of 10ml/kg/10 min in an average volume of 24±0.8 ml/kg, which was stopped with a decrease in systolic blood pressure to the level of 60.0±1.5 mm Hg. HBO was commenced on post-hemorrhagic minute 10 following the regimen of 3 ATA for 60 min.Results. The decrease in CBF and PO2 in SMC develops as early as the 10th minute of hemorrhagic shock, progressing to the stage of hemorrhagic shock decompensation (60±14 min). Accumulation of Am in the SMC at the stage of hemorrhagic shock decompensation associated with stimulation of PDG and GDG activity, inhibition of hemorrhagic shock activity and deficiency of α-KG. HBO, without eliminating hypoxia in SMC, prevented the development of the decompensation stage in animals with GS, pathological accumulation of Am, and a decrease in the activity of hemorrhagic shock. HBO increases the Gn increment from the SMC, into the blood. Under HBO conditions, the stimulating effect of hypoxia on GDG activity remains, but the concentration of glutamate remains within the normal range, as does the activity of PDG.Conclusion. Hyperbaric oxygenation, without eliminating hypoxia in SMC, which develops in hemorrhagic shock, prevents a violation of the exchange of ammonia in it, caused by acute non-compensated blood loss.

Objective — to study prevention of cardio-cerebral complications of metabolic syndrome on the basis of mathematical methods of forecasting.Subjects and methods. A discriminant analysis of clinical and instrumental data of patients with MS.Results of this study allow the early (prenosological) stages of the metabolic syndrome using the linear discriminant equations to predict thedevelopment of myocardial infarction up to 89.3 %, stroke — up to 87.8 %.Conclusion. The diagnostic and treatment algorithms developed based on the stratification of cardiovascular risk index, allow us to give sound recommendations for targeted prevention of cardio-cerebral complications.

Central nervous system (CNS) involvement in advanced non-Hodgkin’s lymphoma (NHL) occurs in 5–29 % of cases. Primary CNS lymphoma (PLCNS) significantly less revealed: 1–2 % of lymphoma cases and 5 % of all malignant CNS diseases. Historically, PLCNS treated with radiotherapy, but the majority of patients had no long-term remission. Combined treatment (chemotherapy + radiation therap y) has been developed to improve radiotherapy efficacy. The research results, according to several authors, allowed to develop the bas is of modern medical approaches, which includes a combination of high-doses methotrexate and cytarabine with radiation therapy for remission consolidation. New drugs — temozolomide, topotecan and rituximab — in combination with conventional preparates have been studied. Treatment results of 11 patients with primary (8) or secondary (3) CNS lymphomas treated in Botkin Municipal Clinical Hospital was analyzed. In 9 from 11 (all with primary lesion) diffuse B-large cell lymphoma w as diagnosed (by immunohistochemistry). All primary patients received 3.5–5 g/m2 methotrexate and 2–4 doses 2 g/m2 cytarabine (except 2 patients); 3 patients in addition received ifosfamide, vincristine and etoposide under a pediatric protocol BFM-90. Subsequently , all patients received 46 Gy cranial irradiation. 75 % of pa tients achieved complete or partial remission. One patient died from infectious complication after 2nd chemotherapy course. 2 patients have early progression. Five patients are alive with follow-up from 6 months to 3.5 years and 4 of them remains in remission. Therapy with methotrexate + cytarabine was accompanied by III–IV grade neutropenia in the majority of patients, but its duration w as not great. The data obtained are consistent with results of modern treatment protocols PLCNS.

Objective: to study the anticolibacillary activity of arterial (aorta) and venous (portal vein, hepatic veins) blood during hepatectomy and hyperbaric oxygenation (HBO).Material and methods: Experiments were conducted on 40 non-inbred female albino rats exposed to hepatic resection (15—20% of organ mass) and HBO at 3 ata for 50 min once daily within the first three days after surgery. The bactericidal action of blood serum against E.coli and the capacity of neutrophils and monocytes to absorb this microbe were investigated.Results: HBO prevents a hepatectomy-induced reduction in serum bactericidal activity in the portal venous blood, but its reduction in arterial blood remains. Along with this, hepatectomy-induced impairment in the capacity of the liver to stimulate the phagocytic activity of neutrophils and monocytes against E.coli is eliminated under HBO. The latter selectively stimulates the rate of venous blood neutrophilic absorption of E.coli, with this property being lowered in monocytes.Conclusion: HBO eliminates the body’s anticolibacillary defense impairments during hepatectomy.

Objective: to study the impact of liver resection (LR) and a hyperbaric oxygenation (HBO) session and their combination on blood antistaphylococcal activity. Material and methods. Experiments were carried out on 77 outbred albino rats (females) exposed to LR (15—20% of the liver weight) and HBO at 3 ata as a 50-min session once daily, which was used in the operated rats in the first 3 days after LR. Serum bactericidal activity against opportunistic (No. 1726) and pathogenic (No. 209) S.aureus strains and the ability of neutrophils and monocytes to absorb S.aureus 209 were studied. Results. restoring the serum bactericidal activity against S.aureus 1726, HBO used after LR enhances its activity against pathogenic S.aureus 209. By decreasing the inhibitory effect of LR on the ability of the liver to enrich blood with the neutrophils that actively phagocy-tize the staphylococcus, HBO eliminates the retention of the monocytes actively phagocytizing S.aureus 209 in the operated organ, by concurrently increasing the count of these cells in the arterial blood. HBO stimulates the rate of uptake of S.aureus 209 by neutrophils in the operated organism when the blood passes through the vessels of the portal system with the partial retention of these cells in the liver portion left after its resection. By selectively suppressing the humoral component of blood antistaphylococcal defense, HBO in healthy unoperated animals stimulates the ability of the liver to enrich the blood with the monocytes that actively phagocytize the staphylococcus. At the same time the rate of uptake of S.aureus 209 by neutrophils is stimulated by hyperoxia. Conclusion. HBO regulates blood antistaphylococcal activity changes in response to LR by exerting a selective effect on the bactericidal activity of the blood against the staphylococcus in rats. Key words: liver, resection, hyperoxia, bactericidal activity, blood, staphylococcus.

The incidence of fat embolism ranges from 0.5 to 30% in injuries with long and pelvic bone fractures; it also occurs in other diseases and conditions. Moreover, mortality accounts for 3 to 67%. There is still no clear idea on the pathogenesis, prevention, and treatment of fat embolism. This review gives current views on this problem. Key words: fat embolism, poly-trauma.

Pulmonary hemorrhage is a severe complication that determines high mortality rates in various diseases and injuries. By reviewing the Russian and foreign literature and their many years’ experience, the authors depict current methods for the diagnosis and treatment of pulmonary hemorrhage. Action algorithms in relation to the etiology, pathogenesis, and degree of pulmonary hemorrhage have been composed for physicians of different specialties. Practical recommendations are given for current perioperative analgesic options during thoracotomy.

Objective: to reveal the patterns of blood biochemical changes, a trend in poikylocytosis, and impairment in the ultra-structure of red blood cells of the whole blood stored in citrate-phosphate-dextrose-adenine-1 during long-term storage. Material and methods. The whole blood that had been obtained from 5 donors aged 25±3 years of different sexes and stored at +2 to +4°С was examined. On storage days 1, 7, 14, 21, and 30, the morphological composition of a red blood cell population was assessed in monolayer blood smears (1000 cells per smear), by using an Olympus BX-500 microscope, computer, and ImageScopeM program. The surface of the red blood cell membranes was analyzed using an IntegraPrima NT-MDT atomic force microscope (AFM). Blood biochemical composition was examined using an i-stat 1® analyzer M: 300. Statistical processing was made with a STATISTICA 7 program. Results. A change in the biochemical composition of the whole blood was revealed within just the first 24 hours of storage. Morphological changes were observed in the red blood cells 3 days later. At 21 days, discocytes were 31.3±3.27% as compared to the control (in the first 24 hours) (p

The review presents the current view of the etiology and pathogenesis of hormonal and metabolic changes in critically ill patients. To build up a system accessible to clinicians to establish an early diagnosis of hypermetabolism syndrome will be able to make differential correction of endocrine and metabolic disorders until decompensated multiple organ failure develops. Key words: critical condition, metabolism, hypercatabolism, somatotropin, insulin-like growth factor.

The paper generalizes the 15 years’ experience of the V. A. Negovsky Research Institute of General Reanimatology, Russian Academy of Medical Sciences, in conducting fundamental studies of the morphological, functional, and clinical patterns of the development of acute respiratory distress syndrome (ARDS), by using up-to-date medical technologies. The developed and clinically introduced new scientifically grounded methods for the prevention, diagnosis, and combination, differentiated treatment of ARDS could reduce the number of complications, the duration of mechanical ventilation, the length of stay in the intensive care unit, and mortality rates. Key words: acute respiratory distress syndrome, V. A. Negovsky Research Institute of General Reanimatology, Russian Academy of Medical Sciences.

Objective: to study the clinical efficiency of undifferentiated and differentiated use of escalation and de-escalation procedures for optimizing positive end-expiratory pressure (PEEP) during mechanical ventilation in patients with acute respiratory distress syndrome (ARDS) resulting from direct and indirect damaging factors. Subjects and methods. During a prospective study, 24 examined patients (16 men, 8 women; their age was 22 to 65 years) with ARDS of different genesis were divided into 2 groups. Group A (n=11; 7 men, 4 women) and Group B (n=13; 9 men, 4 women) included patients with ARDS arising from both direct (gastric content aspiration, blunt chest injury with lung contusion, and acute bilateral bacterial pneumonia) and indirect (abdominal sepsis, severe nonthoracic injury, and acute massive blood loss) damaging factors. The results of treatment via differentiated or undifferentiated, according to the cause of ARDS, use of escalation and de-escalation procedures for PEEP optimization were assessed in Groups A and B patients. Results. The differentiated, according to the cause of ARDS, use of escalation and de-escalation procedures for PEEP optimization makes it possible to more effectively improve the parameters of pulmonary gas exchange and biomechanics and to reduce the length of respiratory support and stay in the intensive care unit, the incidence of ventilator-associated pneumonia, and mortality rates in patients with ARDS resulting from direct and indirect damaging factors. Conclusion. It is advisable to apply the differentiated, according to the cause of ARDS, approach to choosing escalation or de-escalation procedures to optimize PEEP in patients with ARDS of different genesis. Key words: acute respiratory distress syndrome, direct damaging factors, indirect damaging factors, mechanical ventilation, positive end-expiratory pressure, escalation PEEP optimization procedure, de-escalation PEEP optimization procedure, lung opening manoeuver.

Objective: to study body glutamine kinetics in hepatic failure and in the course use of hyperbaric oxygenation (HBO). Material and methods. Experiments were performed on 210 female albino rats. HBO was thrice conducted at 3 ata as a 50-min session once daily after hepatectomy (HE, 15—20% of the liver weight); glutamine levels were measured in their visceral organs and blood from the following vessels: the aorta, v. porta, v. hepatica, v. renalis. Results. By eliminating the glutamine-excretory dysfunction of the operated liver, HBO corrects its glutamine deficiency. At the same time, HBO activates glutamine production by gastrointestinal organs with its further incretion into the portal blood flow. It also stimulates the absorption of glutamine by lung tissue and its deamidation in the latter, but causes a reduction in myocardial glutamine concentrations. By stimulating the development of arterial hyperglutaminemia, HBO prevents the development of transient glutamine deficiency in the splenocytes and delayed postoperative portal hypoglutaminemia. HBO does not exert a substantial impact on brain tissue glutamine changes, but it regulates renal glutamine kinetic changes induced by partial HE. Conclusion. Hyperbaric oxygen used for hepatic failure induced by HE recovers body kinetic disorders of glutamine in this abnormality, by concurrently regulating the adaptive changes in its metabolism in the organs, which occur in response to liver damage. Key words: glutamine, metabolism, hepatic failure, hyperoxia.

The extensive introduction of invasive diagnosis and treatment methods into medical practice is inseparably linked with the necessity of catheterizing the vessels to monitor patient status and to administer medications and other agents into the vascular bed. This results in increased number of cases of catheter-related blood stream infections, which are more than 60% of hospital-acquired bacteremias and 11—37% of all nosocomial infections in Europe. The association of sepsis with an infected catheter is 20—29 to 55%. No specific clinical manifestations of catheter septicemia (and hence its late diagnosis and delayed treatment) and difficulties in identifying a venous catheter as a source of a septic process make it necessary to pay particular attention to the prevention of infectious complications both when placing a central venous catheter and when applying a venous access. Various preventive measures have been developed to reduce the incidence of infections. The measures decreasing catheter-site or infusion system colonization are most effective. Key words: puncture, catheterization, venous access, central venous catheter, colonization, infection, nosocomial infections, catheter-related blood stream infections, septicemia, catheter sepsis.

Objective: to study the efficiency of respiratory, non-respiratory, and pharmacological treatments in patients with acute respiratory distress syndrome (ARDS) induced by direct (aspiration pneumonitis, bilateral pneumonia, or lung contusion) and indirect (abdominal sepsis, polytrauma, or hemorrhagic shock) damaging factors. Subjects and methods. The results of treatment were retrospectively analyzed in 185 patients (122 men and 63 women whose age varied 18 to 69 years) with ARDS resulting from aspiration pneumonitis, bilateral pneumonia, or lung contusion (84 patients, including 53 men and 31 women) or from abdominal sepsis, polytrauma, or hemorrhagic shock (101 patients, including 69 men and 32 women). The efficiency of a lung opening maneuver, mechanical ventilation in the prone position, Surfactant BL, perftoran, and their combination use in ARDS developing due to direct and indirect damaging factors was studied. Results. The study treatment modalities were ascertained to show varying clinical efficiency in patients with ARDS caused by direct and indirect damaging factors. Conclusion. The findings made it possible to substantiate the necessity of setting off ARDS induced by direct and indirect damaging factors, to develop and propose new approaches to the differentiated treatment of different forms of ARDS. Key words: acute respiratory distress syndrome, direct damaging factors, indirect damaging factors, thoracopul-monary compliance, lung extravascular fluid, respiratory support, mechanical ventilation, positive end-expiratory pressure, lung opening maneuver, prone position, perftoran, surfactant.

Objective: to study the specific features of the mechanisms responsible for the development of acute respiratory distress syndrome (ARDS) induced by direct and indirect damaging factors and to reveal its differential diagnostic signs. Materials and methods. Lung morphological changes were studied creating experimental models of ARDS of various genesis in 75 outbred male albino rats weighing 300—400 g, which included the direct damaging factor acidine-pepsin aspiration (Group 1, n=25) and the indirect damaging factor blood loss (Group 2, n=50). Prospective examinations were made in 73 patients (43 men and 30 women, whose age was 21 to 69 years) with ARDS caused by direct damaging factors, such as aspiration pneumonitis, pneumonia, blunt chest injury, and pulmonary contusion (37 patients, including 21 men and 16 women) and in those with ARDS caused by indirect damaging factors, such as abdominal sepsis, severe concomitant injury, and hemorrhagic shock (36 patients, including 22 men and 14 women). Results. The study has shown that ARDS caused by direct and indirect damaging factors is characterized by different developmental mechanisms and lung morphological changes that underlie the specific features of functional impairments. Conclusion. The findings made it possible to substantiate and propose new approaches to the differential diagnosis and treatment of ARDS caused by direct and indirect damaging factors. Key words: acute respiratory distress syndrome, direct and indirect damaging factors, thoracic and pulmonary compliance, lung extravascular fluid, positive end-expiratory pressure, respiratory support, intensive care unit.

The paper covers the problem associated with the wide availability and uncontrolled use of over-the-counter medicines, particularly analgesics, antipyretics, and anticatarrhal agents, which lead to the occurrence of adverse drug reactions and poisonings and to considerable economic and human losses. The mechanisms of the pathogenesis of drug agranu-locytosis due to the intake of nonsteroidal analgesics and the diagnosis and treatment of this disease are described in detail. The case presented by the authors clearly demonstrates that the possible development of life-threatening complications due to the use of even submaximal permitted doses of widely spread and available anticatarrhal drugs. Key words: antipyretics, analgesics, nonsteroidal anti-inflammatory drugs, drug agranulocytosis, trepanobiopsy, myelo-gram, intensive care unit.

By analyzing the data available in the Russian and foreign literature and their many years’ experience, the authors review the state-of-the-art of the problem associated with ventilator-associated pneumonia in intensive care units. The etiology, epidemiology, and pathogenesis of ventilator-associated pneumonia, the possibilities and limitations of its prevention and diagnostic methods, successes and difficulties and treatment of this pathology are described in detail.

Objective: to analyze the causes of fatal outcomes in victims with severe concomitant injury (SCI) in an intensive care unit (ICU) of a multidisciplinary hospital. Subjects and methods. The data on 78 victims with SCI (65 men, 13 women) with SCI without the leading severe brain or spinal injury were retrospectivly analyzed. Results. Intrahospital mortality was 17.9%. The dead and surviving victims had an APACHE II score of 18.4±9.8 and 9.2±7.9, respectively (p=0.0008). According to the ISS scale, injury severity was 41±11.8 scores in the dead and 34.8±10.7 scores in the survivors (p=0.07). The APACHE II and ISS scores were of little prognostic use — AUC (the area under the ROC curve) was 0.19 and 0.35, respectively. Gender and the estimated blood loss volume had no statistically significant impact on mortality. In the structure of mortality, 21.4 and 78.6% fell on early (in the first 5 days after injury) and late (on day 12 or later post-injury), respectively. Late mortality was associated with septic complications in 90.9%. To predict the risk of septic complications, we developed a model including the APACHE II condition severity on admission, chest, limb, and pelvis injury severities. The sensitivity and specificity of the obtained criterion were 87.5 and 84.5%, respectively (AUC 0.88). Conclusion. In SCI, mortality at a present-day multidisciplinary hospital remains high, largely due to late mortality associated with pyoseptic complications. Our developed model may be used in the assessment of fatal septic complications for differentiated prophylaxis.

Objective: to study the informative value of the oxygenation index as a criterion for the diagnosis of acute respiratory distress syndrome (ARDS) of varying genesis. Subjects and methods. Seventy-two patients, including 27 women and 45 men, aged 19 to 65 years admitted to an intensive care unit for various diseases, in whom ARDS was diagnosed on the basis of the traditional criteria, were prospectively examined. The authors analyzed the causes of acute respiratory failure, the time course of changes in gas exchange and PaO2/FiO2, X-ray picture, and the time of respiratory support when respiratory and nonrespiratory treatments were performed. Results. After correction of the extrapulmonary causes of impaired gas exchange, optimization of respiratory support parameters, and use of aggressive artificial ventilation methods and nonrespiratory treatments, 45 (62.5%) of the 72 examinees diagnosed as having ARDS showed a considerable gas exchange improvement and a steady increase in the oxygenation index more than 300; thus, these patients stopped meeting the criteria of ARDS. Conclusion. The oxygenation index is a rather vulnerable sign of ARDS, the time course of changes in which depends on many pulmonary and extrapulmonary causes, which necessitates a comprehensive evaluation of the degree of lung injury, the causes and severity of respiratory failure and, evidently, the refinement and expansion of the criteria for establishing this diagnosis. Key words: acute lung injury, acute respiratory distress syndrome, acute respiratory failure, oxygenation index.

Based on the analysis of the references given in the Russian and foreign periodicals, the present paper states the current notions of the etiology, epidemiology, and pathogenesis of and the methods for the diagnosis, prevention, and treatment of acute lung injury developing with the use of blood preparations. It shows the difficulties arising in the diagnosis of this complication and presents the algorithms of differential diagnosis and treatment of acute posttransfusion lung injury. The authors describe their own observation of a case of evolving acute posttransfusion lung injury, the used methods of diagnosis, and the results of treatment in detail.

The article concerns some ecological aspects of therapeutic features of speleotherapy. The objective of our study was to investigate the therapeutic activity of speleotherapy for respiratory disorders according to it's ecological aspects. The results of including speleotherapy into the curative and prophylactic complex in the central-chernozyom region showed the decrease of incidence of respiratory pathology in people, who underwent the course of speleotherapy. The obtained data indicated, that speleotherapy was supposed to be used as a component of prophylactics complex in treatment for broncho-respiratory complex.

Objective: to study the clinical efficiency of escalation and de-escalation procedures for optimizing positive end-expiratory pressure (PEEP) during mechanical ventilation (MV) in patients with acute respiratory distress syndrome (ARDS) resulting from direct and in indirect damaging factors. Subjects and methods. During a prospective study, 46 examined patients (30 men, 16 women; their age was 21 to 67 years) with ARDS of different genesis were divided into 2 groups: 1) 22 patients (14 men and 8 women) in whom the causes of ARDS were direct damaging factors: gastric content aspiration, blunt chest injury with lung contusion, and acute bilateral bacterial pneumonia; 2) 24 patients (16 men and 8 women) in whom the causes of ARDS were indirect damaging factors: abdominal sepsis, severe nonthoracic injury, and acute massive blood loss. In Groups 1 and 2, the efficiency of the escalation and de-escalation procedures for PEEP optimization was compared during controlled MV with a managed object. Results. In the patients with ARDS caused by direct damaging factors, the escalation procedure for PEEP optimization was more effective than the de-escalation one. In those with ARDS caused by indirect damaging factors, the de-escalation procedure for PEEP optimization was more effective than the escalation one. Conclusion. It is expedient to use a differential approach to choosing an escalation or de-escalation procedure for PEEP optimization in patients with ARDS induced by direct and indirect damaging factors. Key words: acute respiratory distress syndrome; direct and indirect damaging factors; mechanical ventilation; positive end-expiratory pressure; escalation procedure for PEEP optimization; de-escalation procedure for PEEP optimization; lung opening maneuver.