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War destroys normal life and is the main factor of human psychological and physical vulnerability. The stress of war is the most powerful pathogenic factor in the emergence, detection and exacerbation of somatic, mental and behavioral disorders. Trauma can affect the functioning of the hypothalamus and pituitary gland, as well as affect the hypothalamic-pituitary-adrenal axis. One of these strong physical types of stress is gunshot injury and, consequently, surgical intervention resulting in metabo­lic and physiological disturbances. During stress, an excessive amount of cortisol is produced, but when the human body is exhausted, the level of this hormone decreases, and then adrenal insufficiency occurs. The article considered secondary adrenal insufficiency that can develop as a result of surgical intervention after combat trauma with massive blood loss, which can be objectively characterized as acute stress in male combatants. It is important to pay attention to the recognition and early prevention of hypoglycemia in adrenal insufficiency. So, continuous glucose monitoring should be used. Although this test is quite safe, it is desirable to have a simpler diagnostic marker that can be obtained without the administration of adrenocorticotropic hormone. It is also recommended to study the level of cortisol in blood serum, pay attention to the deficiency of sex hormones. Measurement of dehydroepiandrosterone and dehydroepiandrosterone sulfate should be included in the laboratory assessment of hypothalamic-­pituitary-adrenal axis function. Dynamic measurements of dehydroepiandrosterone have proven to increase the accuracy of diagnosing adrenal insufficiency. Thus, adrenal insufficiency can cause non-specific symptoms in a person who has acute stress. Early detection and testing based on clinical suspicion can prevent further development of adrenal crisis.

Background. The purpose was to investigate the features of the migration of foreign bodies of gunshot origin when the heart and great vessels are injured. Materials and methods. Eighty-two wounded people were examined who had blind gunshot wounds of different location, were admitted to the Military Medical Clinical Center of the Northern Region between May 2014 and May 2024, and had the phenomenon of migration of foreign bodies of gunshot origin in different directions. Eleven (13.4 %) patients had the foreign body migration through the vascular bed. All the wounded were male, the average age was 34.2 ± 0.4 years. The medical history, data of objective clinical and general clinical and laboratory studies, as well as the results of instrumental diagnosis were studied. Depending on the location of the wound, all the injured were subjected to spiral computed tomography of the head, thoracic organs and abdominal cavity, X-ray of the head, thoracic organs and abdominal cavity, limbs, video bronchoscopy and video gastroduodenoscopy, ultrasound of the neck, chest, abdomen and soft tissues. Patients underwent primary surgical treatment of wounds, suturing the wounds of blood vessels and heart, and removal of foreign bodies. A surgical magnetic instrument was used for diagnosis and removal of ferromagnetic foreign bodies. Results. According to the location of the entrance hole during the migration of a foreign body of gunshot origin, the distribution was as follows: neck — 1 (9.1 %), chest — 4 (36.4 %), abdomen — 5 (45.5 %), extremity — 1 (9.1 %) case. According to the place of the beginning of the foreign body migration through the vascular bed, the distribution was as follows: left jugular vein — 1 (9.1 %), right subclavian vein — 1 (9.1 %), heart — 3 (27.3 %), portal vein — 1 (9.1 %), left renal vein — 1 (9.1 %), right renal vein — 1 (9.1 %), inferior vena cava — 3 (27.3 %), right superficial femoral vein — 1 (9.1 %) case. According to the foreign body fixation during vascular migration, the distribution was as follows: right internal carotid artery — 1 (9.1 %), heart — 3 (27.3 %), right pulmonary artery — 2 (18.2 %), left pulmonary artery — 3 (27.3 %), portal vein branch — 1 (9.1 %) case. By the site of the entrance hole, where migration of a foreign body occurred later, primary surgical treatment was performed in 6 (54.5 %) cases; in 5 (45.5 %) cases, it was not indicated. According to the place of the beginning of the foreign body migration through the vascular bed, the operative interventions were as follows: colotomy on the left, ligation of the jugular vein — 1 (9.1 %), laparotomy, suturing the wound of the portal vein — 1 (9.1 %), laparotomy, suturing the wound of the renal vein — 2 (18.2 %), laparotomy, suturing the inferior vena cava wound — 2 (18.2 %) cases. In 5 (45.5 %) cases, surgery directed to the place of the beginning of migration through the vascular bed was not performed. According to the place of the foreign body fixation during vascular migration, the interventions were as follows: colotomy on the right, arteriotomy, removal of the foreign body, suturing the artery — 1 (9.1 %), thoracotomy, pneumotomy, arteriotomy, removal of the foreign body, suturing the artery — 5 (45.5 %), thoracotomy, dissection of the right atrium, removal of the foreign body, atrial suturing — 3 (27.3 %), laparotomy, venotomy, removal of the foreign body, vein suturing — 1 (9.1 %) case. In one (9.1 %) case, the foreign body was not removed from the branch of the portal vein. In two (18.2 %) cases, repeated surgical interventions were performed for repeated intraoperative migration of a foreign body from one side to another along the system of pulmonary arteries in the scope of thoracotomy, pneumotomy, arteriotomy, removal of a foreign body, and artery suturing. Ten (90.9 %) foreign bodies were removed using a modern magnetic surgical instrument. There were no complications or deaths after operative interventions in case of migration of a foreign body of gunshot origin through the vascular bed. The average bed-day was 21.3 ± 2.1 days. Conclusions. Among all directions of migration of foreign bodies of gunshot origin, 13.4 % of cases occur in the vascular bed, which indicates the rarity of such a course of injury. Abdominal and chest injuries predominate by the site of the entrance hole during the migration of a foreign body of gunshot origin. According to the place of the beginning of the foreign body migration through the vascular bed, cases with damage to the heart and the inferior vena cava predominate. By the location of the foreign body fixation during migration through the vascular bed, cases with fixation of a foreign body in the pulmonary artery and heart prevail. All operative interventions in case of migration of foreign bodies of gunshot origin through the vascular bed are open. When comparing surgeries for the migration of a foreign body of gunshot origin through the vascular bed, interventions by the site of the foreign body fixation prevail over those by the site of the beginning of migration and by the site of the entrance hole.

Background. The purpose of the work is to develop gradation correction models, methods, and test software that can be quickly applied to improve X-ray and computed tomography (CT) images in automatic mode under conditions of time constraints, as well as significant distortion of the dynamic range of density due to the presence of high-density metal objects, significant manifestation of the gloss effect. Materials and methods. To achieve this, experiments were planned and conducted to obtain CT scans of the organs of interest with metal fragments of the given types placed in them. All the fragments were photographed and measured by a group of independent experts for the possibility of further comparative analysis by classical and computer methods, evaluation of the quality of improved images by numerical and visual methods. Results. Based on experimental data, a new unified model, method and test software for gradation correction of X-ray and CT images have been developed, the use of which allows you to significantly improve the quality of images (up to 5 times in the sense of increasing contrast) in real time (most often, the processing time of one image does not exceed 1 second). The proposed model, method and software are unified in terms of file formats, automatically adjust to the density scale and process data. Conclusions. The developed model, method and software make it possible to achieve the goal of the work — to provide prompt improvement of X-ray and CT images in automatic mode in conditions of lack of time, as well as significant distortion of the dynamic range of density, significant manifestation of the gloss effect. This makes it possible to quickly and qualitatively diagnose gunshot wounds. High efficiency is confirmed by the results of numerous experiments and implementation. At the same time, thanks to a one-time adjustment by a highly qualified expert, the proposed software can be applied with high efficiency in a mass order using preset parameters.

The aim is to demonstrate a clinical case of blast injury of the chest and spine against the background of a complete mirror image arrangement of internal organs. Clinical case. The injured S., 37 years old, received a blast injury during mortar shelling. Upon admission, the injured person complained of aching pain in the area of the X rib on the left and in the lumbar region. The pain worsened during movement. He has known about the malformations of internal organs since childhood, but only about the right-sided location of the heart. The final established diagnosis is combined blast injury of the chest and spine. Closed chest injury on the left, closed fracture of the X rib on the left. Closed fracture of the lumbar processes L3-4 on the right. Congenital malformation. A complete mirror image arrangement of internal organs. The injured person was taken to a territorial hospital base for further treatment, where he received painkillers, anti-inflammatory therapy, and prescribed multivitamins. The total bed-day was 7 days. The injured was taken to the Military Medical Commission and discharged in satisfactory condition to implement the decision of the Military Medical Commission. Conclusions. A congenital malformation in the form of a complete mirror image arrangement of internal organs is a rare pathology. Diagnosing a complete mirror image arrangement of internal organs is not difficult and is an accidental finding during the examination for the injury in this case. Anamnestic data help in the diagnostic search. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of a participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Background. The purpose is to demonstrate the possibilities of mathematical methods when studying the migration of foreign bodies of gunshot origin. Materials and methods. Eighty-two cases of gunshot shrapnel blind wounds of different localization over a certain period were analyzed, where there was migration of a foreign body in different ways. All the wounded were male, the average age was 43.2 ± 4.1 years. According to the type of migration of foreign bodies of gunshot origin, we distinguish the following directions: respiratory tract, gastrointestinal tract, vascular bed (main veins and arteries, heart), urogenital tract, in cavities (pleural, abdominal, pericardial, joint), in soft tissues during suppuration, when the source is a foreign body that moves along the flow of pus. When calculating the migration distance, the average anatomical dimensions of the organs were used. The size and weight of foreign bodies that migrated as a result of a gunshot wound were determined. To calculate the main indicators, the following data were taken into account: time of detection of a foreign body after injury (minutes), distance of migration at the time of detection of a foreign body (cm), time of estimated end of migration (removal of a foreign body) (minutes, months), distance that a foreign body can make (cm), number of cases of migration. Mathematical calculations are based on Newton’s equation of motion. According to the results of mathematical calculations, the following data were obtained: the average speed of migration by the direction of migration, the calculation of the root mean square error for the speed, the interval of finding the average speed, the calculated distance that the foreign body will make. Results. According to the size of foreign bodies of gunshot origin, which migrated, the distribution was as follows: up to 5 mm in the largest dimension — 18 (19.8 %), from 5.1 to 8 mm — 73 (80.2 %) cases. The average weight of removed foreign bodies that migrated was 4.2 ± 0.4 grams. The number of detected foreign bodies that migrated was 91, of which 90 were removed and one was not removed. Single foreign bodies accounted for 79 (96.3 %), multiple — 3 (3.7 %) cases. An expected time during which a foreign body can cover the average possible distance was estimated: based on the results, the average speed of movement of a foreign body of gunshot origin on different parts of the human body was calculated, taking into account the time of wound detection; the average time of the approximate end of migration (removal of the foreign body) and the average distance that the foreign body can make are evaluated; it is calculated in what expected time a body can cover the average possible distance of migration at an average speed. Conclusions. The average speed of migration by the direction of migration and the calculated distance that the foreign body will make allows you to predict the location of the foreign body by the direction of migration, which affects operative access and the scope of surgical intervention. All foreign bodies of gunshot origin that migrated were small or medium and weighed up to 5 grams. Features of the anatomical structure and function of organs by the direction of migration affect the prediction of the location of the foreign body.

Background. In modern military conflicts, the frequency of gunshot wounds to the chest is 8–12 %, of which 79.4 % are nonpenetrating, and 20.4 % are penetrating, with damage to intrathoracic organs. The aim is to demonstrate the peculiarities of diagnosis and operative treatment of a penetrating gunshot wound to the chest with damage to the mediastinum and thymus. Materials and methods. Patient M., 33 years old, was wounded to the chest during mortar shelling. An hour after the injury, he was taken to the frontline surgical team in a satisfactory condition, a chest X-ray was performed. After 4 hours, he was taken to the Military Medical Clinical Center of the Northern Region of the Medical Forces Command and hospitalized to the emergency department. The diagnosis was made of an isolated gunshot bullet blind penetrating wound to the chest with damage to the mediastinum and the presence of a foreign body (bullet) in the area of the aortic arch. Results. Data of chest multislice computed tomography upon admission: a 5.45 mm caliber bullet in the anterosuperior mediastinum at the level of the aortic arch. A video esophagogastroduodenoscopy was performed, damage to the esophagus was ruled out. Sternotomy was performed. A foreign body (bullet) was removed from the thymus with a magnetic instrument under the control of an electronic-optical converter, drainage of the sternotomy wound was performed. The final diagnosis was established: an isolated gunshot bullet blind penetrating wound to the chest with damage to the mediastinum and the presence of a foreign body (bullet) in the thymus. On day 3 after surgery, the drainage was removed from the mediastinum. Subsequently, after 2 weeks, the stitches were removed, the patient was presented to the military medical commission and discharged from the hospital. During the histological examination of a fragment of the thymus tissue, a large hemorrhage, fullness of venous vessels, phenomena of involution and transformation into adipose tissue were revealed. Conclusions. Gunshot wounds to the chest with mediastinal injury are rare. The use of modern magnetic surgical instruments allows the removal of ferromagnetic foreign bodies in case of mediastinal trauma. When choosing the scope of primary surgical treatment of the thymus wound, it is necessary to consider its role in providing the immune system and apply an organ-sparing approach.

The global interest and substantial challenges on this subject contribute to its relevance. This analysis centers on the implementation of artificial intelligence within the medical field, with a specific focus on its application in managing wounds. Through an examination of numerous online studies and publications, we can gain insight into how artificial intelligence is being employed to enhance the diagnosis, treatment, and monitoring of wound healing. The integration of artificial intelligence in this sector has the capacity to transform medical practice by improving precision, effectiveness, and individualized patient care. As a result, it is a leading area of research and advancement on a global scale. We used the PubMed and Google Scholar electronic databases of medical publications, searching for abstracts using the following key phrases: artificial intelligence and wound management, artificial intelligence and gunshot wounds, artificial intelligence and war medicine, artificial intelligence and surgery. Based on search results, a literature analysis was performed. Conclusions. It is necessary to create numerous working groups of highly qualified specialists from each discipline and direction of medical activity, where the specific weight of each symptom, laboratory indicator, each radiological and ultrasound examination result is determined based on the data of real cases. And such work should have no less discipline and structure than medical research, it is optimal to get a universal software tool for this stage of work, which can be used with certain variations for the whole variety of pathological conditions and processes.

Background. The massive russian military aggression against Ukraine has been continuing from February 24, 2022, and has caused the number of individuals who received combat wounds and psychological trauma to be significantly increased. After experienced traumatic events, the psychological changes appear first. They further strongly impact the physical condition of people. The acute stress which occurred after body injuring can further lead to the altering in the endocrine system. It is necessary to point out that during military conflict in Ukraine, the studying of hormonal influence on the particularities and rate of wound healing hasn’t been carried out. Therefore, the purpose of this work was to determine the connection between wound volume and altering of some hormone levels in blood serum at different stages of wound healing process in male combatants. Materials and methods. One hundred and twenty male combatants who were divided into 4 groups of 30 individuals depending on the wound volume have taken part in our investigation. The first group was the minor injuries; the second group — the moderate wounding; the third group was the serious injuries, and the fourth group (controls) included not wounded combatants. The certain periodization has been used depending on the processes which occur in the body in particular period: days 1–3, 4–5 and day 14 after wounding. The average age of patients was 34.2 ± 4.3 years, average body mass was 78.0 ± 3.5 kg. The concentrations of human growth hormone, testosterone, adrenocorticotropic hormone, aldosterone, thyroid-stimulating hormone, free triiodothyronine, free levothyroxine and dehydroepiandrosterone sulfate were evaluated. Results. The activating of practically all chains and complexes of endocrine system is its usual reaction to the injury. The main links between wound volume and serum hormone levels of combatants at the different stages of wound healing process have been revealed in our research. Conclusions. The metabolic response which occurs in human body independently of trauma severity is associated with necessity of the functioning of all organs and systems at the highest level in order to save lives of victims. The altering of all kinds of metabolism occurs. The metabolic signs of urgent adaptation are formed in the acute period of wound healing process related to katabolic processes. After that, the normalization of homeostasis with activating of anabolic processes gradually occurs. A positive correlation was found between the hormone levels and severity and term of injuring of male combatants. The continuation of monito­ring the hormonal status of male combatants with the involvement of large number of participants and detailing of wound localization, endocrinological history, neurological and mental status, hemodynamic parameters and the system of homeostasis is appropriate.

Background. The purpose is to investigate metal non-opaque foreign bodies of firearm origin. Materials and methods. Five cases of removing soft tissue foreign bodies of gunshot origin were investigated, when radiography of the limb soft tissues didn’t detect foreign bodies, but they were removed during the primary surgical wound debridement. X-ray of soft tissue gunshot wounds found no foreign bodies. To study radiographic density, foreign bodies were placed in a foam model with subsequent multislice computed tomography. For spectral analysis of metal foreign bodies, we used wavelengths unconventional for X-ray, which allowed to conduct X-ray fluorescence and X-ray structural studies. Results. Radiographic density of metal foreign bodies ranged from 989 to 2123 HU. Given the different thickness of foreign bodies, from 0.4 to 3.2 mm, the average was 1700 ± 189 HU. The foam had radiographic density of –969 HU with model dimensions of 200 × 100 × 50 mm. When examining samples of foreign bodies, it was found that they are deformed, have different thicknesses. One of the samples is light and smooth on one side, and dark and rough on the other. X-ray fluorescence results: composition on the light side (% by mass): Al — base, Mn — 0.8, Fe — 0.3, Zn — 0.1, Cr — 0.05, Ti — 0.2, corresponding to Al-Mn alloy. The dark side is an oxidized Al-Mn alloy. In the spectrum of the dark side of the sample, the Br-Kα line was detected, which indicates the participation of bromine compounds in the oxidation process. From the smooth side of the sample, the spectrum of this line is not determined. Conclusions. Non-opaque metal foreign bodies of gunshot origin are a rare phenomenon. Metal foreign bodies with low radiographic density are non-ferromagnetic, the use of modern magnetic surgical instruments will not be effective. Visualization of metal foreign bodies, which are not determined by radiography, is possible with the help of multislice computed tomography. The use of the wavelength of primary radiation, which is unconventional for X-ray spectral analysis, and original X-ray optical schemes allows for quantitative determination of the composition and structure of any metal foreign bodies.

Background. The purpose is to determine the place and role of oblique projections in the analysis of multislice computed tomography (MSCT) data in gunshot wounds. Materials and me­thods. More than 3,300 MSCT studies performed in wounded and traumatized patients over a certain period in the Military Medical Clinical Center of the Northern Region of the Medical Forces Command were prospectively studied. All the wounded were male, the average age was 42.1 ± 2.4 years. MSCT of the head, thoracic and abdominal organs, pelvis, and limbs was performed. The frequency of using oblique projections and their informativeness were studied. Results. A prospective study demonstrated that coronal, axial, sagittal projections, and 3D modeling were used in 100 % of cases, and in 21.4 % — oblique projections to improve MSCT results. The distribution by localization of MSCT was as follows: head — 32.9 %, neck — 7.6 %, chest organs — 32.2 %, abdominal organs — 22.3 %, limbs — 5.0 %. MSCT in angiomode was performed in 3.5 % of injured and traumatized patients: head — 27.2 %, neck — 18.4 %, chest organs — 28.9 %, abdominal organs — 23.7 %, limbs — 1.8 %. Oblique projections in MSCT data analysis were used when studying the wound channel in 82.3 % of cases, to improve the visualization of vessels during MSCT in angiomode — in 12.6 % and to improve the visualization of bone fracture lines — in 5.1 %. Conclusions. In the structure of MSCT studies, the head, thoracic organs, abdominal organs, neck, and limbs prevail by localization (in descending order). Oblique projections are used is 1/5 of cases and allow to improve the visualization of the direction of the wound channel, vessels during angiography and lines of flat and long tubular bone fractures.

Background. Modeling allows investigating both existing and predicted processes and is widely used in basic science and in many industries. The aim is to develop a mathematical model for determining the size of the foreign bodies (FB) and their radiographic density in non-biological and biological models to improve the results of diagnosis for gunshot ricochet wounds. Materials and methods. In the biological non-living model (a piece of pork) and non-biological models (polystyrene, foam rubber), we place the FB made of paper, leather, rubber, plastic, and lithium-ion batteries. The number of the FB is 9 of each type. Number of models is 3 each: pork, polystyrene, foam rubber. We measure the dimensions of the FB and models with a metric ruler. For each model, we select the FB, which we label with the study number. We immerse the FB to the same depth using a Billroth general surgical medium hemostatic clamp in the following sequence: paper, leather, rubber, plastic, and lithium-ion battery. Multislice computed tomography (MSCT) of the models is performed on the Revolution EVO (2021) apparatus with measurement of the sizes and radiographic density of the FB and models. Radiographic density was measured in conventional units on the Hounsfield scale. For each study group, the ratio of the actual sizes of the removed FB and according to MSCT data was determined in the MathCad 15 computer math software, depending on the radiological density of the FB and the model. Results. According to MSCT data, the radiographic density of the models on the Hounsfield scale is as follows: polystyrene — –990.0 ± 0.3 units; foam rubber — –985.0 ± 0.2 units; pork — 62.0 ± 0.3 units; radiographic density of the foreign bodies: paper — –743.0 ± 10.3 units, leather — –258.0 ± 14.2 units, rubber — –12.0 ± 2.6 units, plastic — 183.0 ± 14.6 units, lithium-ion batteries — 3071 units. Visualization of paper in non-biological and biological models and leather in non-biological models is problematic due to the similar radiographic density of the models and the inability to measure the dimensions. When the FB (rubber, plastic, battery) is immersed in polystyrene, the coefficient of length (CL) is 1.0612, the coefficient of width (CW) is 1.928; in foam rubber: CL is 0.9926, CW is 1.9641; in pork: CL is 0.8394, CW is 1.534. Comparing the average coefficients of the ratio (CL and CW), we find that the coefficient in a biological model is closest to 1. This means that the FB from rubber, plastic, and batteries are best detected in pork. Conclusions. The actual dimensions of the FB placed in biological and non-biological models differ from those obtained by MSCT. Data correction is performed through calculated coefficients for length and width. The radiographic density of the model affects the radial visualization of the FB. The use of mathematical modeling in determining the sizes and radiographic density allows reducing the measurement error and determine the structure of the FB.

Background. In recent years, spore-forming bacteria of the Ваcillus species, as the brightest representatives of exogenous microflora, have attracted the attention of researchers. One of the most studied probiotics with proven probiotic activity, high efficiency and safety are Bacillus, species of non-pathogenic spore-forming bacteria. The use of probiotic disinfection in medical institutions is a promising direction for the prevention of antibacterial polyresistance in the fight against nosocomial infection. The goal is to analyze the effectiveness of combinations of Bacillus probiotic cultures in the intensive care patients. Materials and methods. The basis of this study is the analysis of the results of a comprehensive clinical-instrumental and laboratory study of clinical, hemodynamic, biochemical indicators, as well as systemic inflammatory markers in 74 patients with combat trauma within day 1–10 of hospital stay, who were treated in the anesthesiology, resuscitation and intensive care unit and the emergency department of the Military Medical Clinical Center of the Northern Region from May 2022 to May 2023. Results. A statistical analysis of the correspondence of identified pathogens to the options of prescribing antibacterial drugs revealed a tendency to decrease in the number of different pathogens per 1 patient during the 10-day stay in the intensive care unit/emergency department. When carrying out a statistical analysis of the changes in intoxication indices, an increase of LII and LI was detected already on the day 1 of treatment; on the day 3 of the study, an upward trend for both studied indices was noted without statistical probability between the groups; оn day 5 of hospital stay in patients of groups I and II, the average LII and LI had a tendency to gradually increase, 11.4 ± 3.2 c.u. and 8.6 ± 1.1 c.u., 4.2 ± 1.7 c.u. and 3.9 ± 0.8 c.u., accordingly, without statistically probable changes due to the large dispersion of each of these indices in the variation series of indicators in patients of both groups; on the day 7 of the study, this trend persisted and these parameters were 10.7 ± 3.6 c.u. and 8.6 ± 1.1 c.u., 4.9 ± 1.2 c.u. and 3.6 ± 0.7 c.u. in patients of groups I and II, respectively; on the day 10 of observation, the average values of LII and LI almost equaled. It is important to determine a probable (p < 0.05) increase in the LII in patients of group I on the day 5 of treatment compared to the day 1: 11.4 ± 3.2 c.u. and 3.2 ± 0.7 c.u., respectively, and on the day 3: 11.4 ± 3.2 c.u. and 5.2 ± 1.1 c.u., respectively. This trend persisted until the day 7 of hospital stay, when the LII was probably (p < 0.05) higher than the index on the first day of observation: 10.7 ± 3.6 c.u. and 3.2 ± 0.7 c.u., respectively, and on the day 3 of intensive care: 10.7 ± 3.6 c.u. and 5.2 ± 1.1 c.u. The average length of stay in the intensive care unit in group I was 16.2 ± 9.6 days, in group II — 12.4 ± 8.9 days without a probable statistical difference between the groups due to the considerable dispersion of this indicator in the variation series among patients. Identical dynamics was determined when comparing the changes of the Sequential Organ Failure Assessment score. Conclusions. The use of combinations of Bacillus probiotic cultures in intensive care patients during 10 days of hospital stay against the background of the de-escalation principle of prescribing antibacterial drugs contributed to the reduction in the number of drugs with antibacterial properties in the treatment protocol.

Background. In modern military conflicts, the frequency of gunshot wounds to the chest is 8–12 %, of which 79.4 % are non-penetrating, and 20.4 % are penetrating with damage to intrathoracic organs. The most challenging task is to choose an approach to penetrating chest wounds due to the inability of verifying the anatomical and topographic nature of the chest wound by non-invasive methods before surgery. At present, there is a tendency to a widespread use of minimally invasive techniques in all areas of surgery. So, the aim of the study is to demonstrate the options of minimally invasive techniques in the diagnosis and treatment of gunshot wounds to the chest with mediastinal damage. Materials and ­methods. Patient G., 36 years old, was wounded to the chest and delivered an hour after the injury to the frontline surgical unit in the state of moderate severity, where he underwent left thoracentesis and pleural drainage. In 4 hours, he was taken to the Military Medical Clinical Center of the Northern Region of the Armed Forces of Ukraine and hospitalized to the emergency department. Diagnosis was made of gunshot shrapnel penetrating wound to the left chest with damage to the upper lobe of the left lung and mediastinum. A foreign body (metal fragment) in the mediastinum. Left-sided hemothorax (300 ml), post-traumatic pneumonitis. Surgery: left thoracentesis, drainage of the pleural cavity by Bülau. A chest and abdominal ultrasound were performed according to the FAST protocol. Laboratory tests were carried out: complete blood count, urinalysis, biochemical blood test, blood coagulogram. Multislice computed tomography of the head, chest, abdomen, and pelvis was performed, as well as video-assisted esophagogastroduodenoscopy and thoracoscopy. Surgical treatment consisted in video-assisted thoracoscopy, revision of the left pleural cavity, removal of a foreign body (metal fragment) from the mediastinum, sanitation and repeated drainage of the left pleural cavity according to Bülau. A foreign body (metal fragment) was removed using a magnetic instrument for endovideoscopic diagnosis and removal of metal ferromagnetic foreign bodies from the abdominal and pleural cavities. Results. Data of multislice computed tomography of the chest on admission were as follows: a 10 × 5 mm metal fragment near the pulmonary artery, post-traumatic pneumonitis along the wound channel. A video-assisted esophagogastroduodenoscopy was done, and esophageal damage was excluded. Surgery was performed: video-assisted thoracoscopy, revision of the left pleural cavity, removal of a foreign body (metal fragment) from the mediastinum, sanitation and repeated drainage of the left pleural cavity according to Bülau. The surgical intervention lasted 30 minutes. On the second day, the drain tube was removed from the pleural cavity. Subsequently, 2 weeks later, the sutures were removed, the wounded man was presented to the military medical commission and discharged to the unit. Conclusion. Gunshot wounds to the chest with mediastinal damage are rare. The use of a modern magnetic surgical instrument allows the removal of ferromagnetic foreign bodies in case of mediastinal injury. The use of minimally invasive surgical interventions for gunshot wounds to the chest with mediastinal injury reduces surgical trauma and can be applied at a specialized level of medical care.

Наведено актуальні питання діагностичного моніторингу зміни судинного статусу в разі використання турнікета при бойовій травмі, а також питання діагностики турнікетного синдрому. Показано альтернативний діагностичний підхід у вигляді додаткового використання поліфокусної експрес-біопсії м’язів і динамічної цифрової термографії. Мета - проаналізувати проблемні питання діагностики та лікування турнікетного синдрому при вогнепальних пораненнях кінцівок для зменшення кількості організаційних і технічних помилок при пораненнях кінцівок, де використовувався турнікет. Матеріали та методи. За 16 місяців широкомасштабної агресії росії проти України в умовах Військово-медичного клінічного центру Північного регіону (ВМКЦ ПнР) проліковано 28 поранених із турнікетним синдромом кінцівок. Усі поранені були чоловічої статі, середній вік становив 34,2±0,6 року. Проаналізовано такі показники: термін накладення турнікета до прибуття на ROLE 2, локалізація турнікета, обсяг оперативного втручання на ROLE 2, термін перебування на ROLE 2, обсяг передопераційного обстеження у ВМКЦ ПнР, обсяг оперативних втручань в умовах ВМКЦ ПнР, кількість випадків гострого ушкодження нирок, потреба в замісній нирковій терапії, середній ліжко-день на ROLE 3, рівень летальності. Проведено класичні загальноклінічні дослідження в поєднанні з термографічним і гістологічним дослідженням. Результати. За локалізацією при вогнепальних пораненнях із турнікетним синдромом переважали поранення нижніх кінцівок (28 (82,4%) випадків) над верхніми кінцівками (6 (17,6%) випадків). Усього вогнепальних переломів при турнікетному синдромі було 12 (35,3%) випадків. Усі (28) поранені надходили з накладеними турнікетами на кінцівках. Термін накладення турнікета до госпіталізації на ROLE 3 становив від 3 годин 10 хвилин до 11 годин 25 хвилин, у середньому - 5 годин 35 хвилин ±20 хвилин. У 5 (14,7%) випадках були проби зняти турнікет при термінах його накладення понад 3 години на рівні ROLE 1. У 6 (21,4%) поранених на одній анатомо-функціональній ділянці було 2 турнікети, що призвело до ампутації на проксимальному рівні. Середній термін перебування на ROLE 2 з турнікетним синдромом дорівнював 60±10 годин. Усім пораненим (28 пацієнтів) із турнікетним синдромом виконали 34 ампутації. 16 (57,1%) поранених із турнікетним синдромом мали гостре ушкодження нирок і отримували пролонговану замісну ниркову терапію. Ця категорія поранених мала турнікетний синдром на рівні стегна. Для діагностики турнікетного синдрому використали поліфокусну експрес-біопсію м’язів та динамічну цифрову термографію. Висновки. Поліпшення підготовки бойових медиків сприятиме зменшенню кількості організаційних і технічних помилок при пораненнях кінцівок, де використовується турнікет. Тривало накладений турнікет призводить до високого рівня ампутації кінцівки в разі непоправних змін у м’язах. Існує потреба в подальшому розробленні об’єктивних методів діагностики турнікетного синдрому. Запропоновані додаткові методи діагностики у вигляді поліфокусної експрес-біопсії та термографії дадуть змогу об’єктивізувати обсяг ушкодження внаслідок стояння турнікета. Дослідження проведено відповідно до принципів Гельсінської декларації. Протокол дослідження ухвалено локальними етичними комісіями всіх установ, що брали участь у дослідженні. На проведення досліджень отримано інформовану згоду пацієнтів. Автори заявляють про відсутність конфлікту інтересів.

Rapid rehabilitation and restoration of the function of damaged anatomical areas in the military is the main goal of military medicine. In the case of gunshot wounds of the knee joint with defects of soft tissues, one of the optional methods of reconstructive and plastic "closure" is the usage of a propeller flap. The clinical case represents a mine-explosive wound of the lower extremities with a defect of the soft tissues of the lateral aspect of the right knee joint in a serviceman of the Ukrainian Armed Forces as a result of artillery shelling in the east of Ukraine in November 2022. There was an isolated shrapnel tangential non-penetrating wound on the lateral aspect of the right knee joint with a soft tissue defect measuring 7.2x3.2-1.0 cm. The aim of the work was to study the thermographic and sonographic features of soft tissue perfusion after gunshot injuries of the lower extremities and on the basis of the temperature dynamics data from the wound surface in combination with the sonographic examination of the vessels to determine the rationality and relevance in the reconstruction of defects of the lower extremities by propeller tactics. Reconstruction with flap with a perforating vessel as the "key" of LSGA (lateral superior genicular artery) and a dynamic multimodal concept (DMT) with the use of audio doppler in the pre-, intra- and postoperative period) with closure of the defect due to a rotary perforating flap with supplying was carried out. During the entire period of treatment, of the injured the temperature background from the surface of the flap was followed up using FLIR C2, and sonographic changes in blood flow were monitored in the projection of the LSGA location. We came to the conclusion that applying the technique of flaps on perforating vessels, several goals are tactically achieved: restoration of the completeness and function of the damaged area, reduction of complications in the recipient and donor areas. Thus, the propeller flap can be classified as a primary option for "replacemen t" of tissues among the restorative tactics of the damaged area of the lower extremities caused by a gunshot origin.

Gunshot wounds to the chest have always occupied a special place among the entire set of gunshot wounds on the human body. Today, the one of the important challenges before the Navy of the Armed Forces of Ukraine, - not only to restore the damaged anatomical structures of the chest, but also to create optimal conditions for the restoration of the functional component. This will make possible to reduce the treatment period of a wounded serviceman and return him to the formation (or to the occupied position) as soon as possible. The use of minimally invasive methods (videothoracoscopy, radiation control and magnetic technologies) during the treatment of a wounded person with a penetrating gunshot wound of the chest is the key in the surgeon’s hands whose task is to save life and eliminate the defect (formed as a result of the wound). This approach is not only an example of highly specialised surgical care for the wounded in the navy, but also demonstrates the high quality of the proposed care scheme. Purpose - practically implement new organisational, tactical and professional approaches to the treatment of gunshot wounds to the thorax using a clinical case study. It is presented the clinical case of wounded man Sh., 35 years old, with a gunshot fragmentation blind wound of the posterior surface of the thorax, gunshot fracture of the Th7 vertebral body on the background of a foreign body (metal arrowhead). In the current world literature, there are many options for surgical tactics for the treatment of wounded patients with penetrating gunshot wounds to the chest. However, our clinical case draws attention to the high relevance of applying and combining minimally invasive techniques (video-othoracoscopy, radiation control and magnetic technology). This makes it possible to reduce the time (or duration) of surgical intervention, perform an «extended» revision of the pleural cavity, examine and assess the condition of the wound canal, remove a foreign body (shrapnel, bullets, arrowhead component), compensate for respiratory failure phenomena as quickly as possible and restore the integrity and function of the thoracic cells. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Background. Diagnosis of metal fragments in the soft tissues of the wounded is based on examination, history, data of radiographic and ultrasound examinations, wound revision. Errors in the diagnosis and treatment of gunshot wounds are due to the complexity of the mechanism, the combined nature of the injury and the inconsistency of seemingly minor changes in severe intracavitary and intratissue damage. One of the new technologies for deepening scientific knowledge is a modern method of X-ray diffractometry using X-ray phase analysis, which is effectively used in the study of metals. Taking into account the metal composition of most final metal fragments of explosive and refractory genesis and the possible diffusion of metal elements into the surrounding capsule, this method is adapted and used to study capsules of metal fragments of explosive and refractory genesis. The purpose of the study: to determine and analyze the intensity of X-ray fluorescence of the contents of the nano-impurities of capsules of metal fragments of soft tissues of explosive and refractory genesis. Mate­rials and methods. As a material for the study of X-ray fluorescence intensity of the nano-impurity content, soft tissues removed surgically together with an encapsulated metal fragment of explosive and fire-fighting genesis were used in 36 wounded in the period from 2 months to 23 years after wounding in a military medical clinic. The center of the Northern region of the Ministry of Defense of Ukraine and the State Institution “IZNH them. V.T. Zaitseva National Academy of Medical Sciences of Ukraine”. Results. Accor­ding to the results of the study of the intensity of X-ray fluorescence of nano-impurities, 3 phases of encapsulation of metal fragments in the soft tissues of the wounded were determined on the basis of elemental, structural, cellular, tissue and clinical data: active dynamic changes, transient phase, unstable equilibrium their absence in most clinical cases. Conclusions. 3 phases of encapsulation of metal fragments in soft tissues of wounded were determined on the basis of elemental, structural, cellular, tissue and clinical data: active dynamic changes, transitional phase, unstable balance, which reflect the main mechanisms of complications and their absence in most clinical cases.

Автори проаналізували організацію надання хірургічної допомоги 4102 пораненим з бойовою хірургічною травмою при проведенні антитерористичної операції / операції об'єднаних сил з 2014 по 2019 роки. Організаційні аспекти системи медичного забезпечення Збройних сил України максимально наближені до стандартів НАТО, щодо застосування в умовах збройного конфлікту. Визначений обсяг та зміст лікувальних заходів на рівнях медичного забезпечення, встановлені напрямки їх удосконалення.