The use of additive technologies in reconstructive maxillofacial surgery

Introduction. Modern technologies make it possible not only to plan reconstructive surgery virtually, but also to manufacture templates for resection and osteotomy, customized titanium plates based on the results of planning. Objective. To analyze the results of application of additive technologies for planning and performing reconstructive operations in the Maxillofacial Surgery and Stomatology Center at Burdenko Main Military Clinical Hospital Patients and Methods. 144 operations to eliminate different locations bone defects were performed in the Maxillofacial Surgery and Stomatology Center in 2007 - 2017. 136 patients (93%) had de-fects of the bones of the facial skeleton and the skull calvarium. In other cases, there were defects of the clavicle (2 patients), defects of the femur (2 patients), defects of the humerus (2 patients), a defect of the radius (1 patient), a defect of the navicular bone (1 patient). Results. Flaps were used to close the defects in 87% of cases (125 patients), and alloplastic implants were utilized in 13% of cases (19 patients). Additive technologies were used in 85% (n = 123) cases for planning the operation to eliminate defects, as well as for manufacturing surgical models and templates. Clinical cases are considered as examples of the use of the additive technologies for planning and performing reconstructive operations to close bone defects of different locations. The incidence of postoperative complications in the group of patients with facial skeleton and crani-al vault bones defects who underwent surgical interventions using templates was 26%, including minor complications - 17.5%, large - 8.5%. Among minor complications, hematomas (5%) and sup-puration (5%) of the recipient wound prevailed, less often similar complications were hematomas (4%) and suppuration (3%) of the donor wound. Large complications were represented by cases of complete (4%) or partial (5%) transplant necrosis. During surgical interventions without a template, it took significantly longer than the average time of grafting and graft formation (212 ± 18.7 min) than during operations with a template, including with a guide for drilling (136 ± 12.6 min, p <0.001) and without a guide for drilling (160 ± 16.3 min, p <0.001). Conclusion. The use of surgical models and templates during reconstructive operations shortens the time of the operation and reduces the number of postoperative complications.

Recurrent acute kidney injury with outcome in chronic kidney disease due to hypercalcemia because of prolonged use of dihydrotachysterol

Introduction. Hypoparathyroidism after hyroidectomy is treated with oral calcium and vitamin-D supplements. Everyday prolonged use of calcium and vitamin D medications can lead sometimes to hypercalcemia that can cause Akute Kidney Injury (AKI) and Arterial Hypertension. We report on a clinical case of a man patient with postoperative hypoparathyroidism who presented with hypercalcemia, AKI and Chronic Kidney Disease (CKD) as a result of prolonged treatment with Dihydrotachysterol and calcium medications. Сlinical case. A male patient, 59 y.o., 11 years ago underwent total thyroidectomy, since that time was daily medicated with l-thyroxine 125-150 mcg, dihydrotachysterol 15 drops (approx. 0,62 mg), calcium in different forms without monitoring the blood and urine levels. He had high arterial pressure up to 200/120 mm Hg, treated with amlodipine 10 mg daily. After 5 years he took onemonth treatment with non-steroidal antiinflammatory drugs for pain relief because of a rib fracture. That time he underwent first AKI with full recovery. After 5 years a few AKI recurred with hypercalcemia. Dihydrotachysterol and calcium were cancelled, but since that time patient kept on getting non-prescribed Dihydrotachysterol and calcium in the same doses. After 1 year more in relapse series a puncture biopsy of the kidney showed nephrocalcinosis, chronic interstitial nephritis and CKD (С4А3) was diagnosed. The patient was treated successfully by dis-continuation of the above drugs, intravenous fluid administration and enhancement of calcium renal excretion. The patient is currently free of complaints for about 3 months. Сonclusion. It is important for clinicians to monitor calcium and 25-OH-D levels in blood serum during the prolonged treatment with calcium and vitamin D medications to prevent a hypercalcemia that can lead to AKI, CKD and other sever complications.

To the 75th anniversary of appellation the name of the Red Army Main Military Hospital to the 1st Moscow Communist Military Hospital

To the 75th anniversary of appellation the name of The Red Army Main Military Hospital to The 1-st Moscow Communist Military Hospital the history of Moscow hospital opening in 1706-1707 was briefly described. Scientific and medical breakthroughs and increasing role of the hospital as a medical, educational and scientific institution for a Red Army military medical service in 1917-1945 was shown in more details. It also included intensive complicated hospital operation period during The Great Patriotic War 1941-1945 (as a part of World War II).

Chronic itch associated with systemic origin in patients of a multidisciplinary hospital

Introduction. Chronic itch is a frequent symptom of internal diseases and causes a significant decrease in the patients’ quality of life. Objectives were to study the structure of internal diseases that cause chronic itch in patients in a multidisciplinary hospital, and the features of chronic itch in these diseases; to evaluate the effectiveness of various treatment regimens for chronic itch in these diseases; to evaluate the possibility of widespread use in clinical practice of the Numeric Rating Scale for the measuring the se-verity of chronic itch in the initial diagnosis and in the determination the effectiveness of treatment. Patients and Methods. Chronic skin itching was studied in patients with various diseases undergoing inpatient treatment at the Burdenko Main Military Clinical Hospital. The study included 125 patients: 20 (16%) with chronic renal failure, 17 (13.6%) with liver diseases, 24 (19.2%) with myeloproliferative, 32 (25.6%) with lymphoproliferative and 32 (25.6%) endocrine diseases. In-dividual antipruritic therapy was selected for each patient with different systemic pathology, considering diseases that cause itching. Results. The most effective drugs in the treatment of chronic itching in patients with chronic renal failure were sorbents, gabapentin and capsaicin in the form of an ointment or cream, with cholestasis - cholestyramine, ursodeoxycholic acid, rifampicin and tacrolimus in the form of an ointment, with true polycythemia - antihistamines and mast cell inhibitors, with Hodgkin's lymphoma and mycosis fungoides - mast cell inhibitors, gabapentin and ointments with glucocorticosteroid additives, with diabetes mellitus - antihistamines, mast cell inhibitors and external therapy with calamine, menthol, capsaicin and glucocorticosteroids, with hypothyroidism - emollients. In patients with myeloproliferative and lymphoproliferative diseases and hyperthyroidism chronic itching completely disappeared only after effective treatment of the underlying disease. Conclusion. For each form of itching and for each patient individual therapy should be selected. The most effective treatment for chronic skin itching associated with systemic origin is the successful treatment of the underlying disease. The numerical rating scale is a reliable scale for measuring the severity of itching, however, it cannot consider all the complexity and features of itching.

The main pathogens of healthcare-associated infections in patients of neurosurgery intensive care unit and antimicrobial activity of the most used antibacterial drugs

Importance. Healthcare-associated infectionsare an important issue in the neurosurgery. The changes in the epidemiological structure of etiological agents, the increase of antimicrobial drug resistance may lead to the ineffectiveness of previously used patterns for the prevention and treatment of healthcare-associated infections. Objective.The aim of the research was to study the microbiological structure of leading etiological agents that cause healthcare-associated infectionsin patients of neurosurgery intensive care unitand to evaluate the effectiveness of the most used antibacterial drugs. Patients and Methods.A retrospective statistical analysis of the results of microbiological monitoring of pathogens of healthcare-associated infectionsin patients of neurosurgery intensive care unitin 2013-2017 was carried out. Results. The share of gram-negative microorganisms among all isolated microorganisms in the period 2013-2017 increased from 42.47% in 2013 to 54.10% and 50.68% in 2016 and 2017.K. pneumoniae, A. baumannii, P. aeruginosa were most often isolated among gram-negative pathogens, and S. aureus, E. faecalis, and S. Epidermidis- amonggram-positive pathogens; the total rate of these six microorganisms progressively increased from 58.91 % in 2013 to 80.51% in 2017. The rateof A. baumanniiincreased from 8.22% in 2013 to 15.58% in 2017 and the rate of K. pneumoniae- from 5.48% in 2013 to 14.29% in 2017, stable significant detectability of P. aeruginosatended to increase (from 9, 59% in 2013 to 11.69% in 2017). Enterococcus spp. was identified at a significantly high level, mainly E. faecalis and E. faeciumwere represented. E. faecalis dominated (10.96% in 2013, 12.35% in 2014, 10.24% in 2015, 8.70% in 2016, 6.49% in 2017) among the isolated Enterococcus spp. A dynamic decrease in the antimicrobial activity of most used antibacterial drugs was revealed. The greatest dynamic decrease in antimicrobial activity was observed in the aminoglycoside antibiotics - gentamicin and amikacin; amoxicillin / clavulanic acid and levofloxacin. The sensitivity to vancomycin and linezolidremained at levels close to 100%. Conclusions.Today recommendations for perioperative antibiotic prophylaxis with cefazolin remain relevant. When conducting empirical antibacterial therapy, it is justified to use a combination of vancomycin with the IIId generation cephalosporins until the results of a microbiological study are obtained. An increase in the rate of resistant microorganisms complicates antibacterial therapy, requires the usage of several antibacterial drugs and increase the importance of preventive actions.

Staged treatment of multifragmentary intraarticular distal radius fracture with the temporary use of Ilizarov external fixator

Introduction. Distal radius fracture is the most frequent fracture in humans. Most authors recommend surgical treatment for intraarticular fracture. A large number of different methods of surgical treatment have been proposed. However, in the long-term treatment no significant superiority of any one method over others has been statistically revealed. Objectives. To study the results of using of Ilizarov external fixation as primary fixation (first step treatment) for the period from injury to final ORIF with a volar locked plate. Patients and methods. The study is based on the analysis of the results of surgical treatment of 81 patients with multifragmentary intraarticular distal radius fractures. These fractures are considered unstable and conservative treatment is not preferred. Patients were divided into 2 groups of 41 and 40 people. In patients of the first group (control group), at the first stage, a closed reduction was applied followed by preoperative immobilization with a classical cast bandage. Patients of the second group (study group) as the first stage of treatment performed fixation of the wrist joint with its distraction in the bridge Ilisarov external fixator. In a few days after reducing swelling all patient had ORIF with volar locked plate. To assess the function of the upper limb in the postoperative period, a DASH questionnaire was used. The results were evaluated at 3,6,12 and 18 months. Results and discussion. In 3 months after surgery revealed a significant improvement in the function of the upper limb (estimated by DASH). After 1.5 years after surgical treatment, no statistically significant difference in the result of treatment was revealed. We suppose that distraction of the wrist joint with Ilizarov external fixator accelerates reducing swelling in preoperative period of time and can improve reduction during ORIF.

Fat embolism syndrome: choice and effectiveness of laboratory diagnostic methods

The review on the use of traditional and new methods of laboratory diagnostics of fat embolism syndrome - a complication that in some cases asymptomatically accompanies severe concomitant trauma is presented. The main currently used laboratory diagnostic methods are described: traditional methods and new markers (interleukin-6, neuroglial protein S100B, surfactant protein SP-D). A review of the literature data in terms of assessing the pathogenetic and diagnostic significance of some methods of laboratory diagnosis of fat embolism syndrome, the relationship between the dynamics of the considered laboratory parameters, the clinical picture and inflammation. Own observation is presented. The results show the importance of integrating the whole range of available methods in the diagnosis of fat embolism syndrome.

Acute Kidney Injury in patients with pneumonia

Mutual complications of impaired lung and kidney function in severe pneumonia (SP) complicated by acute kidney damage (AKP) are considered. The lungs and kidneys perform some similar functions, such as detoxification and regulation of acid-base balance. Lung damage is complicated by dysfunction or impaired renal function, and vice versa, AKI depressively affects lung function. Initially, all organs and tissues, including the kidneys, suffer from hypoxemic respiratory failure. SP is characterized by increased production of inflammatory mediators, decay products of microorganisms and their toxins and ejection them into the bloodstream. Endothelial vascular insufficiency, disseminated microvascular thrombosis, central hemodynamic disorders develop, and as a result, multiple organ failure develops. With the development of AKI, the elimination of uremic toxins and water is disrupted, hyperhydration is formed with an increase in the volume of extravascular water in the lungs on the background of the already existing broken airborne barrier. Uremic toxins depressively affect the heart muscle on the background of an acute pulmonary heart. There is evidence of a negative effect of mechanical ventilation on kidney function, and, conversely, of an adverse effect of AKI on the need and duration of ventilation. The progression of TP and AKP disrupts the acid - base balance due to excess CO2, impaired H+ ion release, and impaired synthesis of HCO3. The pathophysiological mechanisms underlying these relationships are complex, and their effect on the course of the disease is significant.

The influence of intraluminal sutures on the postoperative stricture formation after the radical retropubic prostatectomy

Introduction:According to the information of Ministry of Health of the Russian Federation 12532 people died of prostate cancer in 2016.Detectability of the prostate cancer is increased over the past few years. It is discovered at earlier stages.Today the best practice of treatment a localized prostate cancer is the radical retropubic prostatectomy. The main method for prevention of postsurgical vesicourethral anastomosis stricture is the formation of sealed anastomosis with a exact comparison of mucous membranes without tissue tension. Purpose of the study: to investigate the early and long-term outcomes of the use of new technology on the number of postoperative strictures of the proximal urethra. Objective: to conduct a comparative study of the effect of intraluminal and non-intraluminal sutures in the vesicourethral anastomosis on the risk of postoperative vesicourethral strictures. Patients and Methods:We have performed 126 radical retropubic prostatectomies from January 2016 to December 2016.Patients are splitted in two groups. In the first group (87 patients) intraoperative vesicourethral anastomosis was performed according to classical scheme with intraluminal sutures.In the second group (39 patients) anastomosis was formed without mucous.When you put a cystourethral anastomosis operating a prostate cancer during a radical retropubic prostatectomy, it is appropriate to use suture without mucous. In our medical center formation of vesicourethral anastomosis is performed with Bicril 3/0 thread.For all patiens 5 ligatures were applied on anstomosis.Anasomosis leakage was checked by filling urinary bladder with 100 ml.All patients were examinated in 3, 6 and 9 months after the operation.The examination included computer tomography of the chest, abdomen and pelvis with contrast, transrectal ultrasonography, ultrasonography of the urinary bladder (to measure residual urine) and uroflowmetry. If the urination rate was below 15 ml/s, retrograde urethrography was performed. Main outcomesUrethral drainage was performed during 10.3 ± 3 days in the first group and during 9.9 ± 3 days in the second group.Vesicourethral anastomosis stricture was observed in 22 (25.2¬%) cases in the first group and in 6 (15.3%) cases in the second group. Сonclusions: This method allows one to avoid the eversion of the urinary bladder which decreases the operation time and probability of the bladder neck injury.

The choosing of method for treatment of severe aortic stenosis in senile patients

Introduction.Aortic valve stenosis is the most common valvular pathology in cardiac surgery patients: aortic valve stenosis correction surgery accounts for 10 to 22% of open-heart surgery. 30% of senile patients with severe aortic stenosis due to severe comorbidity and high operational mortality are denied prosthetics of the aortic valve under cardiopulmonary bypass. With the appearance of endovascular correction - minimally invasive surgical treatment methodsthe problem of choosing a method of correction of severe aortic stenosis in these patients arose. Objectives. To select a method for surgical correction of severe aortic valve stenosis in senile patients, determine the place of intra-aortic valvuloplasty in treatment, and create an algorithm for treatment of senilepatients. Patients and methods. The study included 122 patients >75 years old with severe aortic stenosis, confirmed by echocardiography (aortic valve area<1 cm2, mean pressure gradient (aortic valve) >40 mm Hg, peak velocity (aortic valve) >4.0 m/s), undergoing treatment at Cardiovascular Surgery Dept of the BurdenkoMain Military Clinical Hospital in 2010 – 2017. Due to the high surgical risk, patients of the first group (n = 89) underwent only conservative drug therapy, patients of the second group (n = 12) underwent prosthetic aortic valve replacement under cardiopulmonary bypass, and patients of the third group (n = 8) underwent balloon aortic valvuloplasty valve, after which 7 of them entered the fourth group, patients of the fourth group (n = 20) performed Transcatheter Aortic Valve Implantation . Results. In the maximum follow-up three-year period, the mortality rate in patients of the first group was 49.5%, the severity of heart failure in most of the surviving patients was at III-IV Class(NYHA); mortality in the second group of observation was 16.6%, there was a decrease in the severity of heart failure - the transition of most patients from III - IV to II Class (NYHA); in 7 out of 8 patients of the third group, after performing aortic valve valvuloplasty, hemodynamic stabilization was noted - in 5 patients there was a decrease in the manifestations of heart failure to III Class and in 2 patients - to II Class (NYHA), all of them entered the fourth group, in which, after performing TIAK the mortality was not notedduring the three-year observation of. Conclusions. In senile patients, surgical treatment of severe aortic stenosis is the method of choice and can significantly increase the one-year and three-year survival. In the group of senile patients with high surgical risk, endovascular correction of aortic stenosis is preferred. Balloon valvuloplasty of the aortic valve can be considered as a stage in the surgical treatment of severe aortic stenosis in patients with extremely high surgical risk. The next step in this group of patients should be performed transcatheter implantation of the aortic valve. The developed algorithm of a differentiated approach to the choice of a treatment method for severe aortic stenosis in senile patients allows a 32% increase (p <0.05) in the number of cases of radical surgical care for senile patients previously considered unpromising due to the impossibility of surgical treatment.