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Most patients with critical illness, regardless of the cause, develop activation of innate and adaptive immunity. This is often a critical process leading to organ dysfunction.The aim of the review is to systematize information on monitoring the immune system in critical illness for physicians of different specialties (anesthesiology and intensive care, surgery, general practice, obstetrics and gynecology).The review includes information from 83 recent national and international publications (mostly from 2023), available in the public domain and found by keyword search.We have summarized the current understanding of the relationship between infections and the human immune system, as well as the clinical application of traditional markers of immune status. We provided data on novel promising markers for the assessment of immunity in patients with various diseases.Limitations of the studies reviewed include the need for additional large-scale clinical trials of even the most promising markers, as well as a synthesis of the evidence for their performance. In addition, immune monitoring is likely to increase the cost of patient care, necessitating the development of more affordable research methods.Conclusion. Almost all disorders in critically ill patients are associated with changes in the immune system. Management of patients based on their immune profile requires determination of a personalized strategy for immune modulation, treatment, and prevention of infection. Advanced monitoring of immune system functions will contribute to the personalization of medicine, and the continuous development of biological technologies will allow to improve its methods.

The search for domestic publications on this publication was conducted in the database on the RSCI website, and foreign ones in the PubMed and Google Scholar databases in the period 2022-2023. Their analysis showed that actively studied approaches to the immunocorrection of sepsis are aimed at changing the content or activity of cytokines, growth factors, the use of immune checkpoint inhibitors, as well as myeloid suppressor cells. When modulating the action of cytokines, a variety of approaches are used, such as changing the affinity of cytokines to their receptors, extending the half-life of cytokines and «fine-tuning» the action of cytokines. For the safe and effective use of bioregulators for immunocorrection in sepsis, additional multicenter studies of their clinical effectiveness are needed, including taking into account the stratification of patients into individual endotypes and the mechanisms of action of bioregulators.

INTRODUCTION. The severe acute respiratory syndrome-related coronavirus-2 (SARS-Cov2) virus is able to interfere with the interaction of angiotensin-converting enzyme with its receptor. Pronation can affect not only the state of gas exchange during Coronavirus disease 2019 (COVID-19), but also blood circulation, as well as the exchange of vasoactive substances. Hemocirculation disorders are essential in the pathogenesis of severe COVID-19.The OBJECTIVE was to assess the level of vascular biomarkers in patients with pneumonia caused by SARS-CoV-2 during proning against the background of various respiratory supportMETHODS AND MATERIALS. The study included 3 groups of patients depending on respiratory support. The first group consisted of 16 patients who received respiratory support with oxygen at a flow of 5–7 liters per minute. The second group included 15 patients who underwent non-invasive lung ventilation. The third group of 16 patients underwent invasive lung ventilation. Blood tests of endothelin-1, B-natriuretic hormone were performed using an enzyme immunoassay kit. The amount of nitrite (NO2) and nitrates (NO3) was determined by the method based on the enzymatic conversion of nitrate to nitrite with the participation of the enzyme nitrate reductase. The reaction recorded the colorimetric concentration of nitrite using the azo dye formed in the Griess reaction.RESULTS. In patients with respiratory oxygen support during pronation, a decrease in the blood level of brain natriuretic peptide was detected. During the prone position maneuver in patients on mechanical ventilation, the concentration of nitrites increased. In an intergroup comparison, in patients of group 3 relative to groups 1 and 2, NO2 and NO3 indicators changed against the background of proning.СONCLUSION. The increased invasiveness of respiratory support in patients with COVID-19 when performing prone positioning is associated with changes in blood levels of nitrites and nitrates.

The objective was to determine the attitude of anesthesiologists and intensivists to the possibility of a complete transition to the use of domestic equipment for mechanical ventilation instead of imported ones.Materials and methods. An anonymous survey of members of the Association of anesthesiologists-intensivists, doctors with experience working on ventilators (code 232870 and 232890), using the Google Forms software service. The survey involved 227 specialists from different regions of the country working in hospitals with both more and less than 1000 beds.Results. At the workplaces of respondents, imported equipment predominates (91.6 %). The majority of experts (92.6 %) believe that the capabilities of domestic equipment relative to imported ones are lower, 0.4 % – higher, 7 % do not see any differences. The main complaints about modern domestic equipment: less reliability (84.1 %), fewer capabilities (71.4 %), worse interface work (60.4 %), worse service (25.6 %). 92.1 % do not consider it advisable to refuse to import devices, although 63.9 % of respondents do not work with domestically produced ventilators at all.Conclusion. Domestic anesthesiologists and intensivists are not ready to use exclusively domestically produced devices in their practical work. It is necessary to improve the interaction of the professional community with manufacturers of domestic respiratory equipment in order to disseminate the positive information about it.

Background. Cold injury is one of the most significant problems for the northern regions of the Russian Federation. Frostbite is defined as a complex of changes caused by the action of low temperatures, which lead to morphological changes in damaged tissue structures. As a result, the skin with underlying tissues and the intercellular matrix, the components of which are collagen fibers, are damaged, which eventually leads to remodeling and a protracted course of the wound process. Morphometric studies in combination with quantitative analysis of microphotographs (histological specimens) using GIS technologies make it possible to distinguish altered collagen fibers under the influence of low temperatures from relatively healthy tissues. The aim of the study. To assess the possibility of using computer analysis of microphotographs in a complex of morphometric studies of collagen fibers in local cold injury. Materials and methods. The study included 84 patients with III and IV degree frostbite of the lower extremities. Morphological study of tissues and microphotography were performed using Leica DM2500 microscope (Leica, Germany). The thickness of collagen fibers was measured based on visual measurements of characteristic areas of the microphotograph. Computer analysis of tissue microphotographs of the zone of cryoinjury was performed using the ArcINFO software (Esri, USA). Statistical processing of the study results was carried out using the SPSS Statistics software package (IBM Corp., USA). Graphs and diagrams were constructed using MS Office Excel (Microsoft Corp., USA). Results. With frostbite, severe tissue damage occurs, accompanied by the destructive processes of the extracellular matrix components. Low temperatures contribute to changes in the width and orientation of collagen fibers in the damaged area. In this regard, a change in the texture of the histological specimen image leads to achange in the numerical characteristics of the standard deviation of the curvature coefficient in the studied area of the microphotograph. Thus, in the late reactive period, the described complex of morphometric studies makes it possible to classify particular microphotograph as having pathological signs or as a sample of healthy tissue.

Background. A significant proportion of patients infected with the SARS-CoV-2 virus had a severe course of the disease required hospitalization and intensive care The objective was to analyze the defects allowed during intensive care of patients with SARS-CoV-2, and to assess the causes of their occurrence.Materials and methods. An analytical study was made on the basis of expert opinions on 60 case histories of deceased patients in the intensive care unit with the main diagnosis: “COVID-19. Community-acquired bilateral polysegmental viral pneumonia ARDS”. To identify the reasons that led to defects in the diagnosis and treatment of patients with NCI COVID-19 in intensive care units, an anonymous survey of 92 anesthesiologists-resuscitators who worked in the “red zone” during the COVID-19 pandemic was conducted.Results. The defects identified by experts can be divided into two main groups: diagnostic defects and treatment defects. ARDS in 25%, PE in 8% of cases were not diagnosed. There was no ECG control and cardiac monitoring in 22%, lung CT in 6.7%, echocardiography in 10% of cases. Consultations of specialized specialists were not held in 11.7% of patients. There were defects in the correction of EBV and ABS in 30%, unreasonable prescribing of drugs in 58%, defects in vasopressor support in 10%, defects associated with mechanical ventilation in 40% of cases. The survey of physicians showed that the defects were based on insufficient knowledge of the governing documents and the limited capabilities of medical organizations to implement the necessary research.Conclusion. The obtained results made it possible to demonstrate the limitations and subjectivity of the existing assessment of the quality of medical care, which sometimes does not take into account the existing conditions for treating patients and the material and technical capabilities of a medical organization.

The aim of the study. To identify the frequency of occurrence of TLR4 Asp299Gly (rs4986790) gene polymorphism and to establish its contribution to the development of organ dysfunction in patients with severe pneumonia associated with A/H1N1 influenza.Materials and methods. The study included 55 patients with severe pneumonia associated with A/H1N1 influenza. Inclusion criteria: severe pneumonia; consolidation/ground-glass syndrome according to chest X-ray/CT. Exclusion criteria: unstable hemodynamics; body mass index > 30; diabetes mellitus; HIV; tuberculosis, oncopathology. Verification of the pathogen in the respiratory swab was carried out using PCR method: A/H1N1 influenza virus RNA was identified. The age of the patients was 47 [38; 62] years. Among all the patients the proportion of men was 47.8 %, of women – 52.2 %. Patients were divided into 2 groups: group 1 included patients with SOFA scale (Sequential Organ Failure Assessment) score ≥ 2 points; group 2 – patients with SOFA scale score ˂ 2 points. Gene SNPs were determined by PCR method using standard kits developed by Research and Production Company “Litekh” (Moscow). Amplification of the TLR4 gene fragments was carried out in a thermocycler Bis-M111 (Bis-N LLC, Novosibirsk). Genomic DNA isolated from whole blood leukocytes using the “DNA Express Blood” reagent was analyzed followed by an amplification reaction. The amplification product was detected in a 3% agarose gel.Results. Multiple organ dysfunction (SOFA scale score ≥ 2 points) in patients with severe pneumonia associated with A/H1N1 influenza was registered in 24 (43.6 %) cases. When analyzing the frequency of occurrence of the minor Gly allele, according to genetic models, the differences were established between patients of the groups 1 and 2 in codominant (p = 0.023; odds ratio (OR) – 8.82 (0.95–81.89)) and dominant (p = 0.005; OR = 12.35 (1.40–109.07)) models.Conclusion. Severe pneumonia associated with A/H1N1 influenza is accompanied by a high incidence of organ dysfunction. The risk of organ failure development is 2.1 times increased in patients with severe pneumonia with identified TLR4 Asp299Gly gene polymorphism, which probably requires further study.

Legal pressure on the medical worker is currently a factor in reducing the prestige of the medical profession. An unfair assessment of the quality of medical care leads to a simplification of approaches to the implementation of legally «risk» treatment technologies and the degradation of healthcare. Significant problems are the insufficient formation of competencies among specialists involved in expert work, and gaps in the enforcement of clinical recommendations. Professional medical non-profit organizations have leverage to improve the situation. The elimination of these shortcomings will contribute to an objective and fair legal interpretation of the actions of a medical worker in medical care.

АКТУАЛЬНОСТЬ: Ведущее место в структуре послеоперационных осложнений занимает послеоперационная пневмония. Учитывая распространенность послеоперационной пневмонии и рост числа хирургических процедур, прогнозирование ее развития является актуальной задачей, позволяющей принять меры по снижению частоты ее возникновения, путем оптимизации периоперационного периода. Несмотря на свою ценность, существующие шкалы прогнозирования послеоперационной пневмонии не обеспечивают отечественных специалистов надежным и постоянным методом, с помощью которого можно стратифицировать риск развития послеоперационной пневмонии в нашей популяции. ЦЕЛЬ ИССЛЕДОВАНИЯ: разработка модели прогнозирования послеоперационной пневмонии на основе выявления факторов риска ее развития. МАТЕРИАЛЫ И МЕТОДЫ: Многоцентровое проспективное исследование, 6844 пациента старше 18 лет, подвергающиеся плановым оперативным вмешательствам на органах брюшной полости. Оценивали 30-дневную летальность и послеоперационную пневмонию. На первом этапе исследования проводилось сравнение между группой с пневмонией и группой без пневмонии исходных данных пациентов, а также факторов, связанных с операцией и анестезией. На втором этапе исследования проводился логистический регрессионный анализ для оценки вклада факторов в развитие послеоперационной пневмонии. На третьем этапе исследования выполнялось построение модели прогнозирования послеоперационной пневмонии по данным многомерного логистического регрессионного анализа. На заключительном этапе производилось сравнение полученной модели с моделями прогнозирования других авторов, встречающихся в мировой литературе. РЕЗУЛЬТАТЫ: Пневмония выявлена у 53 пациентов (0,77 %). Летальный исход наблюдался у 39 пациентов: у пациентов с пневмонией в 15 случаях (28,3 %), а без пневмонии — в 24 случаях (0,4 %). Ретроспективно с учетом полученной модели к группе высокого риска развития пневмонии были отнесены 933 пациента, частота развития пневмонии составляла 4,5 %. В группе низкого риска развития пневмонии — 5911 пациентов, частота развития пневмонии составляла 0,19 %. ВЫВОДЫ: Выявлены восемь независимых переменных, связанных с послеоперационной пневмонией: длительность операции, курение, полная функциональная зависимость, периоперационная анемия, требующая применения препаратов железа, интраоперационное применение вазопрессоров, III функциональный класс по классификации Американского общества анестезиологов, применение бронходилатирующих препаратов по поводу хронической обструктивной болезни легких, высокий операционный риск. Модель прогнозирования послеоперационной пневмонии имеет отличную прогностическую значимость (AUROC = 0,904).

Introduction. Important links in the pathogenesis of cold alterations are vascular damage and powerful systemic alterations. The presence of premorbid pathology and the duration of the wound process negatively affects to the function of most organs and systems, including the kidneys. Renal insufficiency in patients with frostbite develops in the acute period of cold damage. This is indicated by a decrease in the amount of urine and an increase in creatinine levels in victims with frostbite. In this regard, the identification and analysis of the dynamics of new markers of renal dysfunction in patients with frostbite is promising both from a scientific and practical point of view.The aim. To investigate the dynamics of changes in serum creatinine, NGAL and cystatin C levels in patients with local cold trauma.Materials and methods. The study included 60 patients with frostbite of the III–IV degree of distal limb segments. The study was carried out depending on the volume of the lesion and the timing from the moment of cryoalteration.The results of the study. In patients with grade III–IV frostbite, an increase in the level of lipocalin and serum creatinine was detected in the blood. The concentration of lipocalin and serum creatinine is directly proportional to the volume of cold-affected tissues. Indicators of lipocalin and serum creatinine decrease in the late stages of cryopreservation. The level of cystatin C significantly decreases during all periods of frostbite; the concentration of the latter does not depend on the severity of cryopreservation.

COVID-19 is a global contemporary issue. Acute hypoxic respiratory failure and associated multiple organ dysfunction are the basics of the new disease pathogenesis. An important characteristic of COVID-19 is the damage to the central nervous system, which determines the peculiarities of the clinical course. In the case of vascular complications (ischemic stroke, encephalopathy, delirium) the prognosis of the disease is more severe. The article presents the experience of a large Russian monohospital in observation and treatment of patients with COVID-19 and neurological complications. It also shows the prospect of neuroprotective therapy in this category of patients.

The objective of the study: to evaluate functional and morphological parameters of cardiac function in patients with pulmonary hypertension and COVID-19.Subjects: The study included 53 patients of both genders with community-acquired multisegmental viral-bacterial pneumonia and COVID-19 who were treated in intensive care units. Patients were divided into three groups according to mean pulmonary artery pressure (mean PAP): in Group 1, mean PAP was < 25 mm Hg, in Group 2, mean PAP was 25-40 mm Hg, and in Group 3, mean PAP was ≥ 40 mm Hg.Results. Patients with COVID-19 and mean PAP > 40 mm Hg were found to have higher values of left and right atrial volume, myocardial thickness, heart rate, and mortality. However, they had lower values of arterial stroke pressure index, arterial compliance, specific peripheral resistance, and lower precapillary response.Conclusion. The severe course of COVID-19 is associated with severe pulmonary hypertension developed during extensive pneumonia combined with concomitant pathology. At the same time, impaired hemodynamics and altered sizes of heart chambers are observed in such patients.

Background. Various methods of respiratory support in combination with prone positioning have been used during the COVID-19 pandemic. The effects of combination of these two factors on hemodynamics are of interest for clinical practitioners.The aim: to evaluate the effect of prone positioning on hemodynamics in COVID-19 patients depending on the method of respiratory support.Materials and methods. The study included 17 patients of both sexes diagnosed with COVID-19-associated community-acquired polysegmental viral and bacterial pneumonia with progressive respiratory failure. The study consisted of two stages. During the first stage, the patients were receiving respiratory support with humidified oxygen (3–7 liters per minute). The second stage was initiated after switching to noninvasive ventilation (NIV). The measurements were performed using a technique of volumetric compression oscillometry on a non-invasive hemodynamic monitoring system KAP CGosm-Globus (Russia).Results. The study showed that prone positioning in patients with severe COVID-19 when switching from oxygen therapy to NIV resulted in a change in the diastolic blood pressure difference module from 2.5 (1.0; 8.2) to 8.0 (5.7; 14.0) (p = 0.016). Escalation of respiratory support led to the changes in the left ventricular outflow tract velocity difference module from 11.5 (9.5; 34.2) to 31.0 (15.7; 42.0) (p = 0.049).Conclusions. Patients with community-acquired polysegmental viral and bacterial pneumonia associated with COVID-19 demonstrated changes in diastolic blood pressure and left ventricular outflow tract velocity as a result of prone positioning following switching from oxygen therapy to NIV.

The aim. To study the prevalence of various combinations of polymorphic variants of genes markers of endothelial function and vascular-platelet hemostasis in the development of diabetic foot syndrome.Materials and methods. In 198 patients with uncomplicated diabetes mellitus and 199 patients with diabetic foot syndrome, the frequency of polymorphic variants of the NOS 786C>T, END1 Lys198Asn, ITGB3 1565T>C (Leu33Pro), F5 1691G>A, F2 20210G>A, MMP9 8202A>G, MTHFR 1298A>C, VEGFA-634C>G genes was studied. Using binary logistic regression analysis, the relationship of various combinations of polymorphisms of the studied genes with the development of diabetic foot was assessed.Results. In diabetic foot syndrome, the most significant contribution is made by the combination of polymorphic variants of the ITGB3 1565T>C (Leu33Pro) and MTHFR 1298A>C genes. With the development of this complication of diabetes mellitus, a combination of the 1565 TC polymorphism of gene ITGB3 and the 1298AA polymorphism of gene MTHFR is 2.1 times more common. The association of the 1565TT polymorphism of gene ITGB3 and the 1298AC polymorphism of gene MTHFR is 2 times more common in diabetes mellitus without complications.Conclusion. The combination of the 1565TС polymorphism of gene ITGB3 and the 1298АА polymorphism of gene MTHFR is associated with the risk of developing a diabetic foot and increases the risk of developing this complication by 2.4 times. The presence of a combination of the 1565TT polymorphisms of gene ITGB3 and the 1298AC polymorphism of gene MTHFR is more common in uncomplicated diabetes mellitus, which suggests its protective effect against the development of diabetic foot syndrome.

The OBJECTIVE of this work was to develop a classification of complications of local cold injury.METHODS AND MATERIALS. The study is based on the results and analysis of the treatment of 132 patients with local cold injury of the II–IV degree of the lower extremities. The victims were hospitalized in the regional center for thermal trauma on the basis of the «City Clinical Hospital № 1» in the period from 2018 to 2019. Post-traumatic complications were detected in 54 patients (40.1 %), of which 32 developed early and 22 patients developed late complications. The remaining 78 patients after discharge from the hospital did not seek medical help again and were under the supervision of a polyclinic surgeon.RESULTS. In the course of the study, it was found that in 32 out of 132 patients in the early period of local cold injury of the lower extremities, sensitivity disorders, muscle weakness, convulsions, impaired coordination of movements, graft rejection, wound suppuration and suture failure, stump necrosis were detected in the affected segments of the extremities. 22 victims developed late complications of local cold injury: trophic ulcers of the stumps of the feet, osteomyelitis with the formation of sequesters, gangrene of the stumps of both feet. As a result of the study and pathogenetic interpretation of the consequences of cryoinjury, a new classification of complications of local cold injury was formed and the criteria for the forms of «cold extremity» were identified.CONCLUSION. Post-traumatic complications were detected in almost half of the victims with local cold injury (54 patients, 40.1 %). Thus, in the early stages of cryoinjury, 32 patients were found to have impaired sensitivity of the affected limb, muscle weakness, convulsions, and impaired coordination of movements; 4 (12.5 %) had treatment complicated by graft rejection; 5 (15.5 %) had wound suppuration and suture failure; 2 (6.25 %) had stump necrosis. In the late period, complications of local cold injury were registered in 22 patients. Of these, 12 (55 %) patients were found to have trophic disorders; osteomyelitis was detected in 8 (36 %) patients; in 2 (9 %) — gangrene of the distal segment of the affected limb.

Background. Diabetes mellitus has been the most common endocrine disease in the world for decades. The growth rate of this disease has become a global pandemic. With diabetes, the risk of developing macrovascular complications increases dramatically, this often leads to serious complications such as diabetic foot.The aim of the study was to determine the levels of «old age proteins» and markers of endothelial dysfunction characteristic to the diabetic foot syndrome.Materials and methods. The study was carried out in the Laboratoryof experimental and clinical biochemistry and immunology of the research Institute of Molecular medicine of the Chita State Medical Academy and included determining of endothelial dysfunction markers (homocysteine, endothelin, NOx, NO2, NO3), MMP-9, GDF-15/MIC-1, CCL11 by solid-phase enzyme immunoassay. Result. Diabetic foot syndrome is characterized by the level of GDF-15/MIC-1 equal to 1440 PG/ml or more, and by NOx that equal to 20 mmol/l or more. When these thresholds are reached, the probability of developing diabetic foot syndrome in diabetic patients increases in 10 and 4 times, respectively, which is confirmed by the results of statistical analysis in the IBM SPSS Statistics Version 25.0 program.Conclusions. Increased levels of GDF-15/MIC-1 protein and nitric oxide metabolites in patients with type II diabetes can be considered as predictors of diabetic foot syndrome. The inclusion of these indicators in the structure of the regression model allows us to diagnose the preclinical stage of diabetic foot syndrome, which in the future will allow us to optimize the management and treatment of these patients.

Aim of the study. To examine the effect of prone positioning on hemodynamics in patients with COVID-19.Materials and methods. The study enrolled 84 patients of both sexes with community-acquired multisegmental viral and bacterial pneumonia associated with COVID-19, who were divided into groups according to the type of respiratory support. The tests were performed using the integrated hardware and software system for noninvasive central hemodynamic assessment by volumetric compression oscillometry.Results. We found that the pulse blood pressure velocity decreased from 281 [242.0; 314.0] to 252 [209; 304] mm Hg/s in patients with severe COVID-19 on oxygen support (p=0.005); volume ejection rate decreased from 251 [200; 294] to 226 [186; 260] ml/s (P=0.03); actual/estimated normalized vascular resistance ratio dropped from 0.549 [0.400; 0.700] to 0.450 [0.300; 0.600] (P=0.002), while the arterial wall compliance increased from 1.37 [1.28; 1.67] to 1.45[1.10; 1.60] ml/mm Hg (P=0.009). Prone positioning of patients on noninvasive lung ventilation associated with a reduction of linear blood flow rate from 40.0 [34.0; 42.0] to 42.5 [42.5; 47.25] cm/s (7=0.04) and arterial wall compliance from 1.4 [1.24; 1.50] to 1.32 [1.14; 1.49] ml/mm Hg (7=0.03). Prone positioning of patients on invasive lung ventilation did not result in significant hemodynamic changes.Conclusion. The greatest hemodynamic changes during prone positioning were found in patients on oxygen respiratory support, whereas the least significant alterations were seen in patients on invasive ventilatory support.

The article presents data on the course of inhalations with a native surfactant administered in two patients (66 and 53 years old) at the late respiratory phase of the new coronavirus infection of COVID-19 (the 22nd and the 19th days from the disease onset) who received non-invasive artificial lung ventilation.Subjects and methods. For inhalations, an AeroNeb™ micropump nebulizer was used; for one inhalation, 75 mg of surfactant-BL was dissolved in 5 ml of isotonic sodium chloride solution. The treatment course included 5 days with 2 inhalations a day.Results. In both patients, upon the end of this therapy with the native surfactant, regression of respiratory failure was noted, the level of respiratory support was reduced to insufflation with humidified oxygen, and rehabilitation measures were started with subsequent discharge from the hospital.

The objective: To determine the level of satisfaction with their work and degree of burnout among anesthesiologists and emergency physicians working in the red zone of a COVID-19 hospital.Subjects and methods. A prospective study was conducted as an anonymous survey of physicians performing their duties in intensive care units of the red zone. 65 specialists were interviewed: Group 1 (52.3%) – trainee physicians, Group 2 (47.7%) – anesthesiologists and emergency physicians.Results. The majority of respondents in both groups noted relatively high satisfaction with their current work. At the same time, the majority of respondents (70.9%) in the group of anesthesiologists and emergency physicians would prefer the previous working conditions to current ones. Also, it was noted that both groups were highly emotionally exhausted.

Relevance. Cold injury is defined as a complex of pathophysiological and pathomorphological changes arising as a result of local or general cooling of the human body. Endothelial dysfunction provokes a powerful cascade of cellular interactions with expressed excretory activity, which ultimately leads to a pronounced remodeling of microcirculation and a protracted process of inflammation in the focus of alterations. Aim of the study. To establish the dynamics of the level of myeloperoxidase and calprotectin in the serum of patients with local cold injury. Materials and methods. The study included 80 patients with III–IV degree lesions in the late reactive period and the period of granulation and epithelialization. The average age of patients was 38 ± 8 years. The myeloperoxidase level was measured on the 5th and 30th days from the moment of cryopreservation using multiplex analysis of blood serum. Results. The level of myeloperoxidase and serum calprotectin increases. In late reactive period (day 5), MPO level in patients with frostbite is 7.25 times higher in comparison with control values, in the period of granulation and epithelialization (day 30), it remains elevated, but only 3.63 times higher than in the control group. In the late reactive period, the level of calprotectin in the blood serum of patients with local cold injury was 4.6 times higher in comparison with control values, and on the 30th day of cryopreservation, the value of calprotectin was 4.5 times higher than in the control group. Changes in the level of myeloperoxidase and serum calprotectin reflect the flow of destructive and reparative mechanisms in tissues during local cold trauma and can be used in predicting an unfavorable prolonged course of the wound process.

The objective: to raise the awareness of medical professionals about one of the stages of investigation – pre-investigation check.Results: the article presents the information on the legal aspects of the review of a report on medical crime (pre-investigation check). It outlines potential legal consequences for a physician at this stage of the legal proceedings. Lawyers' advice on the principles of conduct for a medical professional during pre-investigation checks is discussed. Physicians, who are the subject for the review of a report on medical crime are advised to take active participation in the proceedings, to clarify the circumstances of the case and potential legal consequences. At the same time, they are recommended to use affirmative defense based on existing regulations and get experienced lawyers involved.

The OBJECTIVE was to study the changes of bioelectric activity of muscles in patients with local cold injury of the feet.MATERIAL AND METHODS. Non-invasive method of cutaneous electroneuromyography was used to evaluate the bioelectrical activity of muscles. The study was conducted in 52 patients with local cold injury of III–IV degree of the lower extremities of the late reactive period and the period of granulation and epithelialization. M-response amplitude, residual latency and propagation velocity of the excitation were estimated.RESULTS. In patients with local cold injury, there was a decrease in the bioelectric activity of the limb muscles proximal to the affected area. M-response amplitude and the propagation velocity of the excitation decreased in the patients in the late reactive period, while the residual latency increased. In patients with frostbite limbs during granulation and epithelialization, there was a tendency to restore the level of bioelectrical activity of muscles relative to the late reactive period.CONCLUSION. The basis of the adverse effects of local cold injury was “chronic” endothelial dysfunction and local neuropathy.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

The relevance of cold injury is due to its high specific weight in the structure of injuries, complexities of complex therapy, and unsatisfactory results of treatment. It is known that in the pathogenesis of local cold injury, the leading role belongs to endothelial dysfunction, which secretes a huge amount of biologically active substances, including matrix metalloproteinases.Aim: to determine the dynamics of the content of matrix metalloproteinases of the second subfamily (MMP-2, MMP-9) in the serum of patients with local cold injury.Materials and methods. The study included 80 patients (60 men, 20 women) with frostbite of the III–IV degree of the foot to the level of the lower third of the leg in the late reactive period and the period of granulation and epithelization.Results. In the late reactive period in patients with cryopreservation, the level of MMP-2 was 3.4 times higher relative to the control (p = 0.011), on day 30 MMP-2 values did not differ from the control parameters (p = 0.103). The level of collagenase B (MMP-9) in patients with local cold injury on day 5 was 14.5 times higher than the control parameters (p = 0.002), on day 30 – 12.5 times higher compared to the control group (p = 0.000094).Conclusion. During the analysis of the data obtained, we can think about the dual nature of collagenases during the processes of inflammation. In a situation of distress, collagenases prevent endothelial dysfunction by eliminating the cellular structures of the endothelium to ensure adequate metabolism in tissues. Their importance as markers of failure of adequate flow of reparative processes is not excluded.

Cold injury is a medico-social problem in regions with a sharply continental climate. The article describes approaches to the diagnosis and conservative treatment of frostbite of the extremities. Particular attention is paid to early prediction of the degree of cold damage and intensive therapy methods.

Reforming of medical personnel training in Russia is on-going and inevitable. However, the transfer to continuous medical education causes numerous questions in practicing medical specialists. The objective is to assess the awareness of anesthesiologists and emergency physicians of future reforms of medical education, their readiness to learning. Methods: 10 questions about important aspects of transfer to continuous medical education were compiled and placed on the website of Anesthesiologists and Emergency Physicians Association (http://ассоциация-ар.рф). Almost 100 specialists from various regions participated in this voluntary anonymous inquiry. Results show the lack of information on continuous medical education among practicing doctors and poor readiness of some specialists to the planned reforming of medical training, as well as the risk that some specialists will stop working in medicine. Conclusion. Some deeper explanation of the reforms is needed, the legislature is to be improved and opinions of specialists are to be monitored.

The number of patients with severe forms of demyelinating polyradiculoneuropathy and respiratory failure is constantly increasing. The current state of health care system and funding of medical services do not allow full compensation of the costs for provision of care for those with this disorder. Goal of the article: the specific clinical case is used to raise the awareness of the need for taking system decisions to provide treatment for the patients requiring continuous respiratory support. Legal regulations and approaches to payment for medical services are to be changed, special centers able to accumulate such patients are to be organized, care at home is to be provided.

Background: Damage to lung surfactant (LS) enabling the lung local immunity may contribute to the development of bronchial inflammation in patients with bronchial asthma (BA). Methods and Results: A 70-day course of 21 LS (Surfactant-BL) inhalations at the dose of 25 mg was added to inhaled corticosteroids (ICS) and short/long-acting bronchodilators or combined inhalers in 13 BA patients. After 21 inhalations, many patients reported lower frequency of cough and profuse expectoration, fewer night and day attacks, resolution of wheezing, resolution or lower frequency of bronchospasm episodes under moderate exercise, and termination (1 patient) or double reduction (8 patients out of 13) of the ICS dose. The values of PFPs in patients at Days 250 and 340 did not differ significantly from the values achieved at Day 41. The mean values at Days 250 and 340 were as follows: FVC =86.4±6.43 (%), FEV1=61.4±8.41 (%), FEV1/FVC =66.5±8.87 (%). Conclusion: LS inhalations improve the condition of patients with BA, allow ICS dose reduction by 2 times, and improve pulmonary function parameters. A total of 70% of patients had quite a long remission of BA symptoms following a 21-inhalation therapy course of the formulation.

Trombotic microangiopathy is heterogeneous group of the diseases united by a community of a histological and clinical implications at difference of pathogenetic mechanisms, presents clinical-morphological syndrome characterizing a lesion of vessels of a microcirculatory channel. Currently thrombotic microangiopathy include thrombotic thrombocytopenic purpura (TTP), atypical hemolytic uremic syndrome (aHUS), heparin-induced thrombocytopenia, HELLP-syndrome. One of the most important triggers of emergence of a thrombotic microangiopathy is pregnancy. The article describes the clinical observation of atypical hemolytic uremic syndrome in obstetric practice.

Objective: to reveal the patterns of a change in heart rhythm and breathing in patients with acute systemic injury due to cold in hypothermic and early posthypothermic periods.Subjects and methods. Thirty patients aged 18 to 60 years (3 groups of 10 patients with mild, moderate, and severe cold injury) were examined in hypothermic and posthypothermic periods. The patient groups did not differ in gender, age, and weight. Within the first 24 hours after admission, all the patients underwent high-resolution Holter electrocardiographic monitoring that recorded cardiac arrhythmias and breathing disorders.Results. During the therapy performed, as the degree of acute systemic cold injury increased, the patients were found to have a heart rate reduction (from 102 [90; 122] beats/min in Group 1 to 49 [38; 58] beats/min in Group 3) and a circadian index increase (from 105 [88; 125]% in Group 1 to 210 [185; 223]% in Group 3). With increased hypothermia, the victims were detected to have progressive cardiac rhythm and cardiac electrical conduction disturbances, such as supraventricular pacemaker migration, single and paired supraventricular premature beats, paroxysmal atrial tachycardia, atrial fibrillations, and ventricular premature beats. There was decreased heart rhythm variability in all the study groups, to the greatest extent in the patents with severe systemic cold injury. Late ventricular potentials were found in 2 and 7 patients with moderate and severe cold injury, respectively. Breathing disorders were recorded in all the study groups, the greatest increase in the frequency and duration of apnea/hypopnea episodes was noted in the patients with severe hypothermia. A fatal outcome occurred in 4 of the 10 patients with critical hypothermia due to the occurrence of idioventricular rhythm with transition to asystole.Conclusion. Systemic hypothermia is accompanied by cardiac rhythm and cardiac electrical conduction disturbances and respiratory depression, which progress with the higher degree of acute systemic cold injury and, in case of critical hypothermia, may lead to a fatal outcome.

Abstract. Cytokines provide important connecting links between immunity, blood clotting, and nonspecific resistance that become altered in local frostbites. The aim of study was to determine the contents of cytokines in blood of patients with local frostbites at various terms following the lesion. Fifty patients, 17 to 50 years old, with frostbites of extremities (grade II to IV) were under observation. Arterial and venous blood, as well as venous blood from damaged and intact extremities were examined. Cytokine concentrations were determined using ELISA technique. It was shown that blood concentrations of TNFα, IL-1β, IL-4, IL-8 and IL-18 reached their maximum at early reactive period of the trauma (a 2.3- to 19-fold increase). IL-1β concentration exceeded appropriate control values during all the periods of local frostbites. IL 18 levels were increased at early reactive period of the trauma. IL-1β and IL-8 concentration at pre-reactive period proved to be higher in arterial blood of damaged extremities, than in effluent venous blood. Both during early and late reactive periods, the levels of pro-inflammatory cytokines in effluent blood from damaged extremities were 1.2- to 8-fold higher than in venous blood from intact extremities, whereas IL-4 levels were 2- to 5-fold lower.

Abstract. The aim was to study the contents TGFα, TGFβ1 and VEGF in blood of patients with local frostbites. 50 men with local frostbites of extremities (II-IV degree) in the age up to 17-45 years old were examined. The patients were classified depending on the time elapsing post-lesion (group 1, early reactive period; group 2, late reactive period; group 3, granulation and epithelization of lesions). Quantitative determination of TGFα, TGFβ1 and VEGF in blood was performed by ELISA techniques. Blood samples were taken at early, late reactive periods and at period of epithelization of local frostbites. It was revealed that the contents of TGFα, TGFβ1 and VEGF were increased in patients’ blood at later terms after local frostbites. VEGF contents in blood of the frostbite patients increased to higher degrees than the values of TGFα and TGFβ1. An imbalance between TGFα, TGFβ1 and VEGF contents in frostbites was observed in cases of lagging repair and unfavorable clinical course. (Med. Immunol., vol. 10, N 4-5, pp 483-485).

Objective: to study the role of a tissue factor pathway inhibitor (TFPI), the metalloproteinase ADAMTS-13, and its inhibitor in the pathogenesis of acute respiratory distress syndrome (ARDS) in A/H1N1 influenza. Subjects and methods. The study enrolled 52 patients of both sexes aged 19 to 40 years with different clinical forms of A/H1N1 influenza, of whom 14 patients developed Stages I-II ARDS in the presence of pneumonia. An enzyme immunoassay was used to estimate the concentrations of TFPI, ADAMTS-13, and its inhibitor, the antibodies of the IgG class. Results. The level of TFPI increased in parallel with the progression of the disease, its highest concentration was found in patients with ARDS-complicated influenza pneumonia. There was a higher relative activity of ADAMTS-13 in patients with moderate pneumonia while this enzyme was relatively deficient in those with ARDS-complicated pneumonia. Conclusion. Relative ADAMTS-13 deficiency is one of the triggers of ARDS in severe forms of pneumonia in the presence of A/H1N1 influenza. The high level of TFPI may predict the development of respiratory distress syndrome in pneumonia in the presence of influenza infection. Key words: A/H1N1 influenza, respiratory distress syndrome, tissue factor pathway inhibitor, ADAMTS-13.

Objective: to estimate the values of microcirculation, hemostasis, and fibrinolysis in patients after hip joint replacement. Subjects and methods. Thirty-two patients were examined after total endoprosthetic hip joint replacement (TEHJR). Microcirculation was explored by laser Doppler flowmetry (LDF). The level of ADAMTS-13 and its inhibitor and the concentrations of tissue factor pathway inhibitor (TFPI), tissue plasminogen activator (t-PA), and tissue plasminogen activator inhibitor-1 (PAI-1) were measured in the patients’ plasma by enzyme immunoassay. Results. Analysis of LDF measurements of the operated limb showed a 1.3-fold reduction in the value of microcirculation as compared with the intact limb in the patients in the early postoperative period after TEHJR. There were 1.3- and 1.4-fold increases in neurogenic and myogenic tones, respectively. The shunting ratio was 15% higher in the operated versus intact limb. The content of ADAMTS-13 was increased by 1.4-fold in the blood of the operated limp. As compared with the control group, the blood level of TFPI in the operated and intact limbs was elevated by 1.8 and 1.6 times, respectively. As compared with the controls, the patients after hip joint replacement displayed 1.9- and 1.6-fold decreases in the blood concentration of t-PA and PAI-1, respectively. Conclusion. In the patients after hip joint replacement, the value of microcirculation was lower, neurogenic and myogenic tones were higher, as well as there were increases in the levels of ADAMTS-13 and TFPI in the blood flowing from the operated limb as compared with the intact one. The plasma content of t-PA and PAI-1 became lower in the post-TEHJR patients than that in the control group. Key words: endoprosthetic hip joint replacement, microcirculation, hemostasis.

The paper describes the way medical and intensive cares are organized to patients with complicated forms of A/H1N1 and seasonal influenzas in the Trans-Baikal Territory in the fall of 2009.

Objective: to evaluate the von Willebrand factor (vWF) collagen-binding activity and to measure the concentration of tissue-type plasminogen activator (t-PA) and its inhibitor (PAI-1) in the plasma of patients with traumatic shock. Subjects and methods. Forty-four patients were examined. The vWF collagen-binding activity and the concentrations of t-PA and PAI-1 in the plasma were measured by enzyme immunoassay. Results. The plasma taken from patients with second-degree traumatic shock showed a 2.5-fold increase in vWF collagen-binding activity, as compared with the controls. With severer injury, the collagen-binding activity of vWF increased by 2.9 times in a group of patients with third-degree shock. It was established that in patients with second-degree traumatic shock, the euglobulin fibrinolysis (EF) time was more 1.6 times longer, the plasma concentrations of t-PA and PAI-1 being decreased by 2 and 1.7 times, respectively. Moreover, in patients with third-degree traumatic shock, EF was 2.1 longer and the levels of t-PA and PAI-1 were 3 and 1.8 times lower. Conclusion. The plasma collagen-binding activity of vWF was increased by 2.5—2.9 times in patients with traumatic shock. The victims with traumatic shock showed 2—3- and 1.8—2-fold reductions in the level of t-PA and its inhibitor, respectively. Key words: shock, hemostasis, fibrinolysis.

Стаття присвячена системному аналізу правових гарантій, які забезпечують соціальний захист державних службовців в Україні, з метою їх класифікації та виявлення прогалин у правовому регулюванні. Забезпечення належного соціального захисту державних службовців є основною умовою для підвищення їхньої мотивації, ефективності та стабільності функціонування державної служби, що, своєю чергою, сприяє підвищенню якості державного управління і зміцненню довіри до державних інститутів. Стаття аналізує існуючі правові гарантії соціального захисту, які охоплюють широкий спектр прав державних службовців: на оплату праці, соціальне страхування, пенсійне забезпечення, охорону здоров’я, а також інші соціальні пільги та гарантії. У науковому дослідженні обґрунтовано необхідність класифікації правових гарантій для полегшення їхнього розуміння та забезпечення належного правозастосування. Автор пропонує декілька підходів до класифікації гарантій, залежно від їх характеру, джерел правового регулювання, суб’єктів захисту та механізмів реалізації, що сприяє більш ефективному застосуванню гарантій на практиці. Особливу увагу в статті приділено виявленню проблем, які виникають у процесі реалізації та захисту соціальних прав державних службовців, зокрема через неузгодженість правових норм, які регламентують різні аспекти соціального захисту. Запропонована класифікація допомагає розглянути всі елементи системи гарантій як єдине ціле, що забезпечує їх комплексну реалізацію. Визначено, що однією з ключових проблем є фрагментація правового регулювання, коли окремі аспекти соціального захисту розглядаються у різних нормативно-правових актах, що ускладнює реалізацію цих прав на практиці. Окремо розглянуто питання співвідношення загальних соціальних прав державних службовців із специфічними соціальними гарантіями, які передбачені для окремих категорій державних службовців залежно від умов їхньої служби. Класифікація гарантій соціального захисту дозволяє побудувати більш прозорий і доступний механізм їх реалізації, що сприятиме підвищенню рівня правової захищеності державних службовців, зміцненню соціальної стабільності в державному секторі та покращенню якості державного управління в цілому.