Vol 23, No 1 (2021)

Active development of the "anti-aging medicine", attempts to slow down biological (including vascular) aging led to the creation of new pharmaceuticals including menopausal hormone therapy. The vascular wall protective mechanism of the hormones is not completely clear, but it was shown that natural estrogens are able to control the condition of the vascular wall, prevent platelet adhesion, control a range of metabolic and trophic and energy processes in the endothelium of the vascular wall, producing antithrombogenic factors, namely their inhibition contributes to the development of atherosclerosis. It is known that standard and low-dose estrogen may restore the impaired antithrombogenic potential of the vascular wall, provided its initial reduction does not exceed 20%. The issue of the role and possibilities of correction of the antithrombogenic activity of the vascular wall with ultra-low dose estradiol remained unresolved. As a "clinical model" for the study of this issue, we formed 2 groups of patients: in the study group patients received ultra-low dose estradiol plus dydrogesterone, subjects from the control group received beta-alanine. Three-year follow-up showed a decrease in antithrombogenic activity of the vascular wall in control subjects after 2 and 3 years of follow-up according to the M.V. Baluda's test versus subjects treated with ultra-low dose estrogen plus dydrogesterone. The decrease of the relative risk of reduction of the antithrombogenic activity of the vascular wall with the use of ultra-low dose estrogen plus dydrogesterone during the first two years was 2.3 times, and during the 3 years of follow-up — 3.8 times versus control. Thus, prescribing only ultra-low dose estradiol plus dydrogesterone for patients with normal antithrombogenic activity of the vessel wall at baseline reliably lowers the risk of long-term reduction of antithrombogenic potential of the vascular wall.

A post-hoc analysis of 338 casualties demonstrating persistent intra-abdominal hemorrhage has been carried out, the proportion of this group being 16.5% in overall casualty structure or 64% in the group of casualties with abdominal injuries. Lethal outcome rate in the studied group was 13%, the complication rate was 53.2%. Traumatic shock was found in 86% of casualties, the greatest proportion was accounted for by the first and second degree (59.1%). Lethality rate in the case of the third degree traumatic shock and terminal state was 34.4%. Injured parenchymal organs and abdominal major vessels showed the greatest blood loss — 2348 ± 250 ml. The time of arrival of casualties with persistent intra-abdominal hemorrhage to the advanced trauma management stage or definitive surgical care stage was virtually similar amounting to 2.6 ± 0.4 hr. Injuries to hollow organs (34.1%) were most commonly found, injuries to parenchymal organs (24.9%) occurred less frequently, the rate of combination of injuries to abdominal internal organs was approximately the same (24.9%). Major vessels injuries were diagnosed only in one casualty (0.3%), while those combined with internal organs injuries — in 37(11%)of casualties. As regards favorable prognosis this group was considered to be the least perspective owing to high rate of hemorrhage and inability to achieve effective hemostasis at the prehospital stage. Thus, persistent hemorrhage was not profuse, and the majority of casualties (88.7%) should be considered as perspective “recipients” to achieve temporary hemostasis at the prehospital stage. It is this approach based on the principles of early pathogenetic management that could reduce the rate of complications and lethality in casualties with persistent intra-abdominal hemorrhage.

A clinical observation of the combined endometriotic lesion of the small intestine and the appendix is given below. Extragenital endometriosis is a rare pathology in which endometrioid heterotopies develop outside the reproductive system organs. At about 18–25% of women suffering from the pelvic organs endometriosis, the intestines are involved in the pathological process. In this regard, it is believed that in most cases its lesion is secondary while the primary lesion of the intestine with endometriosis is rarely observed and occurs as a result of hematogenous introduction of endometrial elements into the intestinal wall. Of all parts of the intestine, endometriosis most often affects the rectum and sigmoid colon (70−80%), then the jejunum, less often the cecum. The most rare gastrointestinal tract endometriosis localization is the appendix, the frequency of its lesion is 0.8%. It was carried out in a clinicopathologic analysis of 14 endometriosis cases in various parts of the intestine (4 cases of the small intestine lesions, 2 — rectosigmoid part of the large intestine, 2 — rectum, 2 — sigmoid colon, 3 — appendix, 1 — combined lesion of the small intestine and the appendix). In most cases, the clinical diagnosis of extragenital endometriosis is difficult, and as a rule women come with complaints typical of acute surgical pathology: intestinal obstruction, appendicitis. An important role in differential diagnosis is given to the ultrasound examination of the pelvic organs and abdominal cavity, magnetic resonance imaging, endoscopic research methods, as well as the connection of clinical symptoms with the menstrual cycle.

Often, when performing reconstruction of nerve trunks, between the ends of the damaged nerve, the presence of diastasis is noted, which requires significant nerve tension in order to overcome it. This, in turn, can lead to a violation of the blood supply to the nerve and damage to its ultrastructures, which leads to unsatisfactory treatment results. The possibility of using intraoperative infrared fluorescence angiography in reconstructive surgical interventions for peripheral nerve damage, in order to assess the degree of blood flow disturbance in the nerve trunk, is considered. In patients with a complete anatomical break during the operation, an attempt was made to overcome diastasis by measuring the tension force (up to 3 N) with which the nerve was affected. Infrared fluorescence angiography with indocyanine green was performed simultaneously. The obtained angiograms were analyzed, and the effect of the tension force on the change in blood flow in the nerve trunk was determined. It was found that when exposed to a force of up to 2 N, there is no significant change in the intraneural blood flow. At the same time, the effect of a force of 3 N is manifested on angiograms by a significant decrease in the volume of blood flow, which is usually due to constriction of the vessels due to their stretching. After reconstruction (microsurgical epineural suture), repeated angiography was performed to assess the safety and adequacy of blood supply to the nerve. It was revealed that the use of intraopreational angiography with indocyanin green is an affordable and easily feasible technique that allows to determine the safety and, equally important, the adequacy and efficiency of blood flow in the nerve trunk. This technique makes it possible to monitor the safety of blood flow in the nerve trunk, to study the mechanisms of compensation of blood supply to the nerve after microsurgical epineural suture, to assess the quality of comparison of nerve stumps along the axis, excluding the possibility of their "twist".

The morphometric parameters and surgical areas of risk of retroperitoneal approach were studied for endoprosthetics of intervertebral discs in the lumbar spine to reduce trauma and reduce the risk of complications. The study included 110 patients operated on in the period from 2017 to 2020 (72 men, 38 women) in the neurosurgical department of the 1586 Military Clinical Hospital. The average age of the patients was 44.9 ± 15.4 years. According to the localization of access to the lumbar spine, the patients were distributed as follows: L_III–L_IV — 8 (7.3%), L_IV–LV — 46 (41.7%), L_V–S_I — 56 (51%). It was found that, for the intervertebral disc L_V – S_I, the length of the skin incision was 92.5 (80; 100) mm, the length of the surgical wound was 80 (80; 110) mm, the thickness of the subcutaneous fat layer was 30 (15; 40) mm, the depth of the wound was to the spine — 85 (70; 120) mm, the depth of the wound to the spinal canal — 125 (107.5; 152.5) mm, the angle of operation in the horizontal plane at the level of the spine — 52 (47; 59.5) degrees. On the basis of the anthropometric data of patients, the optimal length of the skin incision was determined for performing the retroperitoneal approach (120 mm for level L_III–L_IV, 100 mm — for level L_IV–L_V). Three variants of the inferior vena cava bifurcation have been identified for different levels of intervertebral discs in the lumbar spine: high bifurcation, left common iliac vein mainly overlaps the left half of the L_IV–L_V intervertebral disc and does not overlap the L_V–S_I intervertebral disc; middle bifurcation, left common iliac vein overlaps the central part of the intervertebral discs L_IV–L_V and L_V–S_I; low bifurcation, inferior vena cava overlaps the right side of the intervertebral disc L_IV–L_V, inferior vena cava and left common iliac vein completely overlap the intervertebral disc L_V–S_I. The data obtained can be used when planning retroperitoneal access to the lumbar spine in order to reduce the trauma of the operation.

The relationship between the level of glucagon-like peptide-1 and repeated weight gain was evaluated in 31 patients suffering from grade II–III obesity and type 2 diabetes mellitus after bariatric interventions for 3 years. It was found that the level of stimulated glucagon-like peptide-1 significantly increased by the third day after sleeve gastroplasty and gastroschunt compared to the initial parameters (p = 0.001 for obese patients; p = 0.000 for obese patients and diabetes mellitus). In the plateau phase (body weight retention) after bariatric intervention, the level of stimulated glucagon-like peptide-1 in obese patients and patients suffering from obesity in combination with diabetes mellitus did not significantly differ from the indicators of healthy individuals. There was no association between the level of glucagon-like peptide-1 and repeated weight gain. This may be due to the limited contribution of glucagon-like peptide-1 to body weight dynamics after bariatric interventions and the predominance of patient compliance. Thus, the level of stimulated glucagon-like peptide-1 at baseline, on the third day and in the plateau phase after bariatric intervention was not associated with the value of repeated weight gain.

The features of the development of traumatic pancreatitis in gunshot wounds of the abdomen, which present difficulties in timely diagnosis, are considered, hypotheses are formulated for studying the problem. Two clinical cases of developing traumatic pancreatitis against the background of a gunshot wound to the abdomen with indirect damage to the pancreas are presented. Without taking into account the peculiarities of the formation of the wound canal relative to the organs of the abdomen, in conditions of limited diagnostic potential, there is a high probability of late diagnosis of traumatic pancreatitis, especially in indirect damage. Injuries to the organs of the upper half of the abdomen can be risk factors for indirect damage to the pancreas due to the effect of lateral impact energy and the formation of a temporary pulsating cavity. In general, the management of such wounded in a surgical hospital with limited diagnostic capabilities or with stage treatment in a local military conflict requires the surgeon to know the peculiarities of the course of traumatic pancreatitis, which make it possible to prevent the development of complications in a timely manner. The development of traumatic pancreatitis in penetrating gunshot wounds to the abdomen is not always a consequence of direct pancreatic injury. This circumstance must always be taken into account during a diagnostic laparotomy.

The article presents the results of a comprehensive anatomical and experimental study of individual variability in the structure and topography of motor branches of peripheral nerves in relation to the justification of methods for selective reinnervation of tissues by the "end-to-side" neurorrhaphy. It was found that relatively longer branches of peripheral nerves with a small number of connecting inter-arm collaterals characteristic of narrow and long limbs create conditions for less traumatic mobilization of motor branches. In cases with relatively wide and short extremities mobilization of peripheral nerves is complicated by the presence of a large number of collateral branches and intra-trunk connections, which are often damaged when separate bundles that make up the mobilized branches of the donor or recipient nerve are isolated from the main nerve trunk. It has been shown that potential recipient nerves should be motor branches of peripheral nerves, the preservation of which is of fundamental importance for the function of the corresponding segment of the limb. To create conditions conducive to selective reinnervation of functionally significant muscle groups of the upper limb, we have developed, justified from anatomical positions, and tested in an experiment on anatomical material methods for connecting the distal motor branches of peripheral nerves by the "end-to-side" neurorrhaphy. The main idea of accelerated recovery of the thumb opposition in injuries of the median nerve is to reinnervate the muscles of the elevation of the I finger due to nerve fibers that are part of the deep branch of the ulnar nerve. For this purpose, surgical techniques have been developed for connecting the recurrent motor branch of the damaged median nerve mobilized at the level of the wrist with the edges of a surgically formed perineurium defect on the lateral surface of the bundles that make up the deep branch of the ulnar nerve. In another clinical situation, in patients with radial nerve injuries, for the muscle reinnervation, а method is proposed for neurotisation of the deep motor branch of the radial nerve by the end-to-side suture to the lateral surface of the median nerve. We assume that performing the "end-to-side" nerve suture at the level of the base of the hand in the cases of proximal damage to the median nerve will reduce the time of reinnervation of the muscles of the thumb elevation by 400–450 days. Transposition of the deep branch of the damaged at the proximal level radial nerve with "end-to-side" neurorrhaphy to the median nerve — by 250–300 days (based on the total length of the shoulder and forearm, which is about 50 cm and the rate of regeneration of nerve fibers 1 mm per day). Accordingly, with higher injuries (brachial plexus), the gain in the time of reinnervation of the distal segments will be even greater. In our opinion, the results can be used as a basis for further clinical research on the development of methods for selective tissue reinnervation in cases with isolated injuries of the peripheral nerves.

It is known that inhalation exposure to chlorine and hydrogen chloride leads to damage to the respiratory system up to the development of acute pulmonary edema in victims. No data on the mechanisms of development of pulmonary edema upon exposure to hydrogen chloride have been found in the available literature. The study was carried out on white outbred male rats, which were divided into 3 groups: Group I — control; Group II — animals were intoxicated with chlorine at a dose of 1.5 median lethal concentration (30 min); Group III — animals were intoxicated with hydrogen chloride at a dose of 1.5 median lethal concentration (30 min). Immediately after exposure to the studied toxicants, as well as after 1, 3 and 6 h, the lung coefficient and the content of cytokines (interleukins-1β, 6, 10 and interferon-γ) in the bronchoalveolar lavage fluid were determined in animals. It was revealed that an increase in the lung coefficient (p < 0.05) in animals in groups II and III was accompanied by a significant increase (1.5 times) in the content of the studied cytokines in the bronchial-alveolar lavage fluid compared with animals in group I. III an increase (p < 0.05) in the content of cytokines is recorded later — only 3 hours after exposure, while it is significantly lower than in animals of group II at all studied periods. Thus, intoxication with hydrogen chloride leads to a slower development of pulmonary edema and an increase in the content of both pro (interleukins-1β, 6) and anti-inflammatory cytokines (interleukin-10, interferon-γ) in the bronchial-alveolar lavage fluid compared to animals, exposed to chlorine intoxication.

Nuclear and radiation safety remains one of the most important components of the national security of our country. The increasing requirements for the medical care system in the Armed Forces of the Russian Federation in case of peacetime acute radiation injuries are due to the impossibility of completely eliminating the risks of radiation emergencies as a result of natural disasters, industrial radiation accidents and the threat of nuclear terrorism. The peacetime three-level system of medical support in the Armed Forces of the Russian Federation has been developed. It is designed to guarantee the first aid, primary predoctor care, primary doctor care and primary specialized health care for victims of acute radiation injuries by medical units, formations and organizations in the territorial zone of responsibility. In 2017 it was completed a research work "Improving the organization of therapeutic care in acute radiation injuries at the stages of medical evacuation in radiation accidents". An analysis of medical service capabilities to provide specialized, high-tech medical care in radiation injuries showed the relevance of the clinical base development in military medical organizations and the importance of interaction with radiological medical centers of other ministries, agencies and services. The solution of these tasks will be facilitated by the creation of a specialized infrastructure on the basis of military medical organizations of the district (fleet), which is providing necessary conditions for the provision of medical assistance to victims of the radiation emergency.

Domestic patents for inventions on surgical treatment of shoulder joint injuries are analyzed. The database of the Federal Institute of Industrial Property of Rospatent was searched. Eliminating the so-called search noise, we created an array of 215 patents for inventions for the surgical treatment of shoulder injuries (registration mainly from 01/01/1994 to 09/30/2020). The average annual number of patents for inventions was 7 ± 1. Surgical treatment methods were presented in 74.3% of inventions, and devices (surgical instruments, endoprostheses, etc.) — in 25.7%. In some inventions, both methods and devices were patented. Inventions for the surgical treatment of shoulder joint instability accounted for 23.4%, for the treatment of tendons and periarticular tissues — 8.9%, for osteosynthesis of the bones of the shoulder joint — 21.9%, for surgical devices and instruments — 14.2%, for methods and shoulder arthroplasty devices — 13.4%; other inventions (on assessment of lesions, the likelihood of a favorable outcome of surgery, pain relief, etc.) — 18.2%. It is necessary to optimize the domestic inventive activity in areas of medicine to prevent a shotage of domestic medical equipment or tools in case of sanctions imposed by certain foreign states.

The article analyzes modern federal programs aimed at preserving the health and well-being of the population and creating a comfortable and safe environment for life and work. The article describes the arsenal of strategic directions for assessing the risk of developing diseases, diagnostic approaches and scientific principles that contribute to the successful implementation of evaluation measures. The possibility of clarifying the cardiovascular risk in the study of the role of military-professional factors in the formation of cardiovascular pathology in military personnel of the Armed Forces of the Russian Federation is discussed. The article analyzes the effectiveness of traditional diagnostic methods used by the medical service, as well as ways to improve this efficiency when using molecular genetic studies to search for associations with risk factors for neuropsychic and cardiovascular pathology. The article considers the practical necessity of creating a professional reliability management platform based on the principles of personalized medicine, which contributes to prolonging professional longevity and improving the combat readiness of servicemen of the Armed Forces of the Russian Federation. Such a method of implementing the professional reliability management platform will significantly increase the informativeness of traditional methods of early diagnosis of cardiovascular and neuropsychic pathology.

The article presents up-to-date information about diagnostic methods for one of the most common and socially significant hepatological diseases-alcoholic liver disease. The most frequent clinical manifestations of this pathology are asthenic, dyspeptic, right hypochondrium, cholestatic, neurological, edematous-ascitic and hemorrhagic syndromes. Validated questionnaires are intended for standardized alcohol use screening, the «gold standard» among which is the «AUDIT» questionnaire aimed at identifying alcohol use disorders. Most of the physical signs of chronic alcohol abuse are presented in the modified LeGo grid. Direct indicators (markers) of laboratory diagnosis of alcohol use include the determination of phosphatidyl ethanol and ethyl glucuronide in blood serum and urine; ethyl glucuronide and fatty acid ethyl esters in hair; ethanol, aminotransferase, peroxidase, ethylglucuronide, ethyl sulfate, haptoglobin, etc., in saliva. Indirect markers include macrocytic anemia, neutrophilic leukocytosis, increased activity of gamma-glutamyl transpeptidase, transaminases, de Ritis coefficient, bilirubin, alkaline phosphatase, serum immunoglobulin A and gamma globulins. Determination of carbohydrate-deficient transferrin is recommended as a preferred marker of alcohol intoxication. In order to determine the degree of fibrosis, predictive diagnostic serum tests are used, both non-proprietary («APRI», «Forns») and commercial («Fibrometer», «Hepascore», «Fibrospect» etc.). The methods of visual diagnostics of liver diseases include ultrasound, magnetic resonance and computed tomography, which can determine steatosis, exclude other causes of liver damage, reveal signs of severe fibrosis or cirrhosis, as well as their complications, but none of them allows to establish the etiology of the lesion. A promising direction is to determine the degree of steatosis when measuring the controlled parameter of ultrasound attenuation, implemented in the «Fibroscan» apparatus. The most accurate methods for diagnosing steatosis today are magnetic resonance imaging of the liver in the mode of determining the proportion of fat, weighted by proton density, and proton magnetic resonance spectroscopy. To determine the degree of fibrosis, a transient, two-dimensional shear wave and magnetic resonance elastography are used. Biopsy followed by morphological examination is the «gold standard» for the diagnosis of alcoholic liver disease, which confirms the presence of liver damage, establishes its stage and often allows confirming alcoholic genesis. However, this procedure has a number of significant drawbacks, so it is advisable to use non-invasive diagnostic techniques for screening, primary examination and further monitoring of the patient’s condition in dynamics. 

Modern biomedical technologies development affords to provide the doctor with colossal amount of information about patient’s organism condition. However, the opportunity of using this data for medical diagnosis fully now is a distantive perspective only. The reason is a human’s limited ability in assessment and interpretation this data arrays. The solution seems in artificial intelligence and expert systems wide introduction to medicine. Currently, almost all authors consider various options for constructing artificial neural networks as a way to implement artificial intelligence. This approach, which goes back to the fundamental theorem of A.N. Kolmogorov, the works of V.I. Arnold and Hecht-Nielsen [3], demonstrates excellent capabilities in a number of pattern recognition problems, which are reduced to revealing hidden details against the background of input noises. Much less often is mentioned such a method of modeling formal thinking as expert systems, which arose in the 1960s and then went into the shadows. Since the inception of cybernetics, computer programmers have tried to reproduce the mechanism of human thinking, that is, the task was to teach the computer to "think". The first known results in the field of creating and using intelligent systems were laid by the work of Norbert Wiener and G.S. Altshuller. At the same time, the creation of intelligent systems was reduced to the development of programs that solve problems using a variety of heuristic methods based on the property of human thinking to generalize.

The basic principles of rational treatment of glomerulonephritis are considered, based on etiology, clinical manifestations and pathomorphological variants of its different forms. Today it has been established that glomerulonephritis can be primary (the etiology is usually unknown) and secondary, when the disease occurs against the background of concomitant pathology (systemic lupus erythematosus, vasculitis, hepatitis, oncological diseases, chronic viral and bacterial infections). The participation of various pathological, genetic and systemic factors in the development of various forms of glomerulonephritis has been shown. The characteristic clinical picture of manifestations of different forms of the disease and the degree of involvement of different renal structures in them are described. Against the background of the severity of the course and prevalence of various forms of glomerulonephritis, it is especially important to develop therapeutic approaches aimed at the full restoration of kidney function and cure of patients. One of such approaches is the use of biomedical cell products based on allogenic mesenchymal multipotent stromal cells and hematopoietic stromal cells. A number of studies have confirmed that the best results can be achieved with the use of cell products in complex therapies with standard treatment methods (use of cytostatics and steroid anti-inflammatory drugs) and alternative drug approaches (combination of monoclonal antibodies and polyenzyme drugs). At the same time, the use of standard and alternative techniques does not lead to a complete recovery of patients, but only transfers the course of the disease from the exacerbation phase to remission. The relevance of further development of biomedical cell products of allogeneic mesenchymal multipotent bone marrow stromal cells is shown, verification of their safety and efficacy in preclinical and clinical studies.

Svistelin Dmitry Pavlovich was born on November 27, 1923 in the town Seredina-Buda in the Ukrainian Soviet Socialist Republic. During the Great Patriotic War, he served in the 164th Tank Brigade of the 16th Tank Corps, which took part in the Battle of Kursk. In one of the battles, Dmitry Pavlovich was severely wounded, but after the Victory of the Soviet Union he found the strength and entered the medical faculty of the Lviv State Medical Institute and graduated form it in 1951. Subsequently, Dmitry Pavlovich came to Smolensk, where he became a postgraduate at the Department of Pathological Anatomy of the Smolensk State Medical Institute. From that moment he paid his debt to the Motherland already as a doctor being the head of the pathological department of the Smolensk Regional Psychiatric Hospital. Subsequently, Dmitry Pavlovich began to teach at the Department of Pathological Anatomy and became interested in scientific activities under the guidance of Professor Vladimir Gerasimovich Molotkov, who later guided him for both his candidate’s and doctoral dissertations. Having achieved a great success in the pathological anatomy and becoming a professor, Dmitry Pavlovich decided to return to practice again. In 1996, he shifted to the post of pathologist in the expert-organizational-advisory department of the Smolensk Regional Institute of Pathology, which even today bears his name due to his outstanding work both for pathological anatomy in general and for Smolensk medicine. For services to the Motherland both as a defender of the Fatherland and as a doctor, Dmitry Pavlovich Svistelin has such awards as the Order of the Patriotic War, 2nd degree, as well as the badge «Excellence in Public Health». On June 16, 2006, at the age of 82, Professor Dmitry Pavlovich Svistelin passed away and was buried at the New Cemetery in Smolensk.

The main aspects of the biography and scientific and pedagogical activities of the outstanding Russian neurologist, Doctor of Medical Sciences, Professor, Corresponding Member of the Russian Academy of Sciences Miroslav Mikhailovich Odinak are presented. Key professional and organizational achievements are considered. Particular attention is paid to the implemented innovative methods of treatment, such as the first systemic thrombolysis operation in St. autologous stem cell transplant for the treatment of amyotrophic lateral sclerosis, the world’s first autologous dendritic cell transplant for the treatment of multiple sclerosis was performed. In the same way, under the guidance of Professor M.M. Odinak, an increase in the bed capacity of the clinic of nervous diseases was carried out, a department of intensive care and intensive care and a day hospital was formed, a department of traditional medicine with rooms for psychotherapy, reflexology, manual therapy, thermal relaxation was opened; department of functional diagnostics of the clinic of nervous diseases with rooms for neurofunctional studies, ultrasound studies, dopplerography, studies of the function of the autonomic nervous system; a physiotherapy department with a hydropathic center, a video electroencephalographic monitoring department and a polysomnography department.