No. 1 (2002)

Steady growth of frequency of defeat stops at a diabetes causes a urgency of a problem. Death rate from complications of a diabetes takes the third place among the direct reasons of death, therefore this problem gets social value.
By the author it is analyzed results of inspection and treatment of 1895 patients which were divided into 4 groups. Control (first) group compose 125 patients; 728 patients with “diabetic foot” which received treatment in hospital formed 2 group; 723 patients by whom economical amputations foots and exarticulation fingers compose 3 group; 319 patients by whom complex treatment was included in long intraarterial catheter therapy formed 4 group.
The analysis of unsatisfactory results of control group has allowed the author to reveal, that a principal cause of progressing is purulent - necrotic defeats stops at a diabetes arc tendon-sinews formations. In view of anatomic features sparing operative interventions arc offered at various localizations of defeat stops which essence consist at a distance interested tendon-sinews environments of fingers stop in view of the developed factor proximo-distal a gradient microbic impurities.
The system of the integrated medical aid by the ill diabetes, consisting of 3 parts with concrete functional duties and including experts of a various structure (diabctologists, surgeons, cardiologists, chiropodists et al.) is developed and introduced.
The technique of realization long intraarterial catheter therapies is advanced at generalization purulently-nccrotic process. She consists in constant drop introduction of 50 % of daily volume and 3-4 times per day strcamly 50 % of daily volume of an antibiotic. The basic components were the preparations improving rcological properties of blood, antibiotics of a wide spectrum of action, spazmolitics. The volume daily solution did not exceed 1-1,4 litres. Thus duration catheter therapies have made 7-10 days.
Application of the developed ways of surgical treatment of a diabetic gangrene of the lower extremities at various localizations of defeat has allowed to reduce frequency of high amputations from 40,8 up to 8,4% and to lower mortality from 12,0 to 3,0%. In the remote period of supervision till 5 years frequency of preservation of basic function of the lower extremities has increased from 38,4 up to 75,2%. It has allowed to improve quality of life due to what mortality in terms till 5th years has decreased from 72,2 up to 24,5%.
Complex treatment of a diabetic gangrene of the lower extremities with use of the advanced technique of realization long intraarterial catheter therapies has allowed to raise in the nearest terms of supervision safety of basic function of the lower extremities from 59,2 up to 78,0%. Lethal outcomes thus has decreased from 12,0 up to 3,2%. In the remote term of supervision (5 years) the number of patients with safe basic function of the lower extremities has increased from 38,4 up to 54,5%. The survival rate of patients thus has increased from 28,8 up to 48,2%.

Relevance of the problem.Despite the great successes of angiosurgery, the problem of surgical treatment of abdominal aortic aneurysms does not lose its relevance. World health statistics records a steady increase in the incidence of abdominal aortic aneurysm (ABA). According to L.J. Melton et al. (1984) and L.K. Bickerstaff et al. (1984) in the USA the number of patients with abdominal aortic aneurysm has increased 7 times in 30 years since 1951. In England and Wales, according to F.G. Fowkers et al. (1989) for the same period revealed a 20-fold increase in abdominal aortic aneurysms in men and 11-fold in women. According to the results of multicentre screening studies ABA was detected in 8% of the examined (E.S. Vourvouri, 2001), and in the age group of 64-69 years ABA was detected in 5.7% of the examined, and in the age group of 75-81 years - in 8.9% (R.A.P. Skott et al., 2001). A similar trend is observed in other countries. Accordingly, mortality from ABA is also increasing - aneurysm rupture in a number of countries is one of the ten most frequent causes of death among elderly and senile people (F.A. Lederle et al., 1990)
Currently, planned aneurysm resection has become a recognised standard of radical treatment of ABA patients and the number of these operations is steadily increasing. For example, about 40,000 ABA resections are performed annually in the USA (J.J. Grange et al., 1997). In Sweden during the period from 1987-89 to 1993-95 the number of ABA operations increased 5 times and currently 10 operations per 100,000 population are performed (A.Hallin et al., 2001), although this is 1.5 - 2 times less than the required number. However, postoperative lethality is still quite high and makes 5-7% (A.V.Pokrovskiy et al., 1992; Y.V.Belov et al., 1992; V.V.Vakhidov et al., 1992; A.W. Bradbury et al. Bradbury et al., 1997; A.Hallin et al., 2001).
E.W. Steyeberg et al. (1995) summarised the data of literature on 17238 ABA resection operations and gave an average mortality of 6.8%.
Multicentre studies in five major hospitals in the Netherlands found that only 74% of patients underwent ABA resection without complications; 26% had some complications, 9% of which were severe and 4.1% of which were fatal (G.J. Akkersdijk et al., 1998). Similar results were obtained in the Canadian Cooperative Study (K.W. Johnston et al., 1990). It was established that the peculiarity of complications in the majority of patients was their systemic character (L.L. Lau et al, 2001) The course of the postoperative period is most often complicated by cardiac, respiratory, renal, cerebrovascular, as well as complications associated with thrombosis and bleeding (W.E. Lloyd et al., 1996; R.D. Sayers et al., 1997; J.D. Blankenstein et al., 1998; R. Ayari et al., 1998). Ayari et al., 2001)
The undisputed leadership, without doubt, belongs to cardiac complications, the incidence of which varies from 10% to 20%. Moreover, cardiac complications account for 50-70% of total mortality. Cerebrovascular complications, although not uncommon, account for no more than 1-1.5%, but their mortality reaches 40%. Complications associated with thromboses and haemorrhages in the perioperative period reach 2-5% (M.M.Reigel et al., 1987; K.W.Johnson et al., 1990; N.Franklin et al., 1993; A.A.Milne et al., 1994).
Certainly, a large number of complications after resection of abdominal aortic aneurysms is caused by the initial severity of patients' condition, however, many unresolved tactical and technical issues of patients' preparation for the operation, stage of performance in case of combined lesions of several vascular basins play a practically significant role. Adequate management of the operation itself and the immediate postoperative period is no less important, taking into account the possibility of such dreadful complications as thrombosis and embolism, cerebral and cardiac death. Until now there is no unified complex analysis of the results of treatment of uncomplicated abdominal aortic aneurysms and, accordingly, recommendations for the prevention of possible complications.
All this determined our aim and objectives of the study.
The aim of the study is to improve the results of surgical treatment of ABA by developing an effective system for determining the main risk factors of surgical treatment and optimal surgical tactics to prevent possible complications.
Scientific novelty.For the first time a complex analysis of indications and contraindications to surgical treatment of abdominal aortic aneurysms was carried out
The most significant concomitant pathology capable to lead to formidable complications and lethality during the intervention and in the nearest postoperative period was revealed. Adequate measures of their prevention and treatment were proposed.
The algorithm of surgical treatment tactics for patients with combined pathology of coronary arteries and aortic arch branch lesions was developed
The state of haemostasis system at all stages of reconstructive surgery on abdominal aorta, starting from skin incision to wound closure, was studied for the first time.
Conclusions:
1. The proposed original classification of ABA, based on mutual dependence on the etiology of the disease, localisation, concomitant diseases, clinic and its course, allows to determine the strategy of early diagnosis, to estimate the most significant risk factors, the stage of intervention in combined lesions of adjacent and distant vascular basins and, ultimately, to determine the ways to reduce complications and mortality in patients with ABA.
2. The most informative methods of ABA diagnostics are duplex scanning and computed tomography. Non-invasive diagnostics capabilities are enough to determine the aneurysm size, its relation to the renal arteries, as well as to find out the state of visceral branches and aortic bifurcation. Abdominal aortography is indicated in patients with concomitant arterial hypertension to identify the state of the renal arteries.
3. Significant risk factors in these patients are ischaemic heart disease (44.1%), arterial hypertension (49%), haemostasis disorders (almost 100%).
4. The leading concomitant disease in the development of postoperative complications is ischaemic heart disease. Its share in abdominal aortic aneurysms is 40%. Postoperative cardiac complications reach 14.9%. Diagnostics of ischaemic heart disease should be based on the stage-by-stage detection of coronary lesions and its functional-compensatory abilities.
5. The main complications of the postoperative period after ABA resections are acute heart failure (14,9%), cerebral circulatory disorders (1,5%), acute renal failure (3,33%).
6. When significant coronary vascular channel lesions are detected in patients with ABA, it is fundamental to solve the issue of intervention staging. At 3-4 functional classes of circulatory insufficiency, appearance of new zones of hypo- or akinesia, decrease of ejection fraction below 40%, the first stage should be myocardial revascularisation surgery
7. In patients with combined lesions of brachiocephalic vessels in patients with ABA it is reasonable to assess the cerebral blood flow. In the presence of 70% or more stenosis of VCA, presence of embologenic plaque, bilateral haemodynamically significant stenosis it is necessary to perform carotid artery intervention as the first stage.
8. One of the most difficult problems of reconstructive operations in ABA is the contiguous lesion of renal and visceral branches of the abdominal aorta. The principle is their one-stage reconstruction. The types of reconstruction of these branches should be variable depending on the volume and extent of the pathological process.
9. Patients with aneurysmal lesion of abdominal aorta initially always have significant disorders of haemostasis system. In 30% of patients with occlusive diseases of aorta and its branches in the preoperative period the activity of thrombocytic-vascular link of hemostasis is increased, antithrombotic ability of vascular wall endothelium is decreased and blood rheological properties are disturbed. Activation of fibrinolysis was noted in patients with aneurysmal lesion of abdominal aorta.
10. During the operation for abdominal aortic aneurysmal lesion, after starting the blood flow the level of plasminogen increases additionally by 30%, which is a risk factor for haemorrhagic complications in the perioperative period. On the 1-3 day after the operation there is a significant decrease of blood anticoagulant potential - antithrombin-Sh by 25-27%, protein C by 23-25%. This period is the most dangerous in terms of thrombohemorrhagic complications development.
11. When using standard heparin during the operation there is a consumption of antithrombin-Sh by 30-45% and increase of platelet aggregation by 10%, which is a threatening condition for the occurrence of thrombosis of deep veins of the lower extremities with subsequent TELA. When using fraxiparin during reconstructive vascular surgeries the consumption of antithrombin-Sh and increase in platelet aggregation do not occur, prothrombin time, activated partial thromboplastin time, thrombin time are lengthened insignificantly that testifies to expediency of its use for prevention of thrombohemorrhagic complications.
12. Application of the diagnostic methods proposed by us to detect the main risk factors during the operation and in the nearest postoperative period, use of the algorithm of stage and volume of intervention allowed to reduce significantly the number of threatening complications, thus the lethality decreased 4 times, and the number of non-fatal complications - 4 times non-fatal complications - 1.5 times.

The present investigation is devoted to the working out of new approaches for diagnosis, monitoring and prognosis of iron deficiency states under pregnancy. Immunoenzyme method for analysis of circulating transferrin receptors pool in blood and express-method quantity analysis of different isotransferrins pool in blood serum with different degree saturation by iron were worked out for puproses of fcrrokinctic monitoring in pregnancy. This tests allow to discover the pre-and latent iron deficiency under early period of pregnancy.
Comparative investigation of two diagnostic indices - transferrin concentration and total iron binding capacity (TIBC) in special pools of serum with different degree satupation by iron was carried out. The definite quantitative disparity between this two fcrrokinctic indexes was shown, the transferrin index is more useful for characteristic of ferrokinctic.
Frcgucncy of iron deficiency under pregnancy by different fcrrokinetics indexes was shown, in third trimester of pregnancy all women arc with hyposidcropcnia by analysis of transferrins receptors level in blood. Among ferrokinctic indexes more informative in complexes diagnosis of iron deficiency is transferrins receptors level in blood.
Metabolism of iron under pregnancy with different fcrrokinctic indexes was studied in 96 pregnant women. The typical changes in all functional funds of iron organism of pregnant women was shown - rises of uncffective iron deficiency erhytropoiessis, shortening of iron reserves. This changes indicate for necessity of constant fcrrokinctic monitoring of pregnancy for the purpose of early diagnosis of pre- and latent iron deficiency.
Effective method of prognosis of developing of latent iron deficiency under pregnancy was worked out, based on analysis of sensitive markers of iron status in organism - transferrin and ferritin of blood scrum and transferrins receptors level in blood.

The main purpose of the work is to invent the molecular association in the solution and pellicle of dyes widely using in food industry, formation of complexes and physical process which arc formed by the means of them and applying the received results to the practice. The following results and conclusions arc obtained by the result of spectroscopic researches conducted in the wide range of concentrations and temperatures (4.5 - 370 K) for dyes and related to them substances used in food industry and on practice.
1. For the molecules of studied substances the coefficient of extinction and meaning of optical activity, quantitative output of fluorescence and phototransformation, force of oscillator, frequencies of pure electronic transition were determined.
2. Structure of molecules and absorption of substances according to the properties of solvent, decrease of absorptive and fluorescent abilities, gipso and batochromic widening of the spectrum by the comparison with monomer molecules arc observed. It was determined that hypochromic effect, observed in the association of molecules was stipulated by the resonance splitting of excited electronic levels of the molecules of food dyes.
3. The formation of the luminescent associates in binary solvents of food dye molecules at the room temperature was observed. Absorption and luminescence bands of associates arc placed in side high length in comparison with those for monomer molecules.
4. It was established that the complicated associates of food dyes arc formed by their dimmers. In this case the angle between flatness of dimmers in the aggregate is 90°, and in the respect of the axis of aggregates growth is 45°.
5. It was shown that the complicated associates of food dyes have needle-shaped structure. These associates arc put under the influence of gravitational field of the Earth. Time and character of the relaxation in the ordering of the associates depends on the molecular mass of the monomer molecules.
1. Half width and position of exiton band of the associates of food dyes molecules were determined. On base of Davidov’s molecular cxitions theory the electron transition energies in dimmer and monomer, the interaction energy difference of excited and non-excitcd molecule in elementary cell of dimmer molecule, the resonant life-time of exiton and other parameters of associates were calculated.
2. Main ways of dcsactivation, and excitation energy for food days molecules and compounds related to them were established:
- for derivatives of corotinoids, arilcthilenes and arilpolienes - inner conversion, isomerization, conformation and luminescence of the molecules of sensibilizated oxygen:
- for derivatives of bctalainc and antociance - fluorescence and sensebilization of singlet oxygen;
-Fordcrivatives of flavon, difcnilbutadicnc and difcnilgecsatricnc 
- fluorescence and inner conversion.
8. Photo and tcrmodcstruction of monomer and associates of the molecules of antociane, bctalainc and flavon were defined. It was shown that quantum output of photodestruction is low for the molecules of antociane and it had big meaning for the derivatives of bctalainc. It was proved that the photodestruction of molecules of dyes pass through the sensibilized molecular oxygen.
9. It was shown, that the formation of the complexes containing different molecules. IR and laser irradiation cuse the rise of photo and thermostability offood dyes. The rise of photo and thermostability of food pigments and vitamins was achieved by pumping the molecular oxygen out of the solution, as result of this it was determined that term of the keeping of dyes increased 3-4 times.
10. Spectrophotometric cells, allowing obtaining the spectra of circular and linear dichroism in the conditions of laminar hydrodinamic stream were worked out and patented.

Актуальность темы. Среди паразитарных заболеваний головного мозга, проблема эхинококкоза на сегодняшний день не только не потеряла, но и приобретает все большую свою актуальность (С.К. Акшулаков, Е.Т. Махамбетов, 2000). Ежегодно в странах Центральной Азии самым тяжелым и опасным гельминтозом человека (Р.М. Ахмедов, И.А. Мирходжаев, Э.Ш. Вахидов, 2001) заражается от 30% до 53,9% местного населения (Ф.Г. Назыров, 1999).
В Узбекистане, по обращаемости в хирургические стационары, уровень заболеваемости колеблется от 4 до 9 на 100000 населения. Количество больных с осложненными формами достигает 25-45%, летальность 2-5%, а количество послеоперационных осложнений 20-30%. В настоящее время отмечается увеличение диагностированных случаев заболевания, что в значительной мере обусловлено улучшением диагностики. По данным аутопсии, пораженность людей достигает 2-3% (Каримов Ш., 1994; Кариев М.Х., Усманов Р.М., Кариев Г.М., 1994).
Эхинококкоз главным образом поражает внутренние органы, такие как печень, легкие, селезенка, почки, что считается типичным для этого заболевания. На долю такого расположения приходится от 85,4 до 89,4% () всех случаев заболевания. Церебральный эхинококкоз изучен меньше, чем поражения других органов, его патоморфологическая диагностика у больных представляет большие трудности (Оморов Т.М., 2001).
Эхинококковые кисты головного мозга являются редкой локализацией зародышевых яиц ленточного гельминта и обнаруживаются в 0,5-2,5 % всех сообщаемых случаев эхинококкоза человека (). Большинство больных обращаются за медицинской помощью не своевременно, в стадии суб- или декомпенсации патологического процесса. Причиной этого является постепенное появление и нарастание клинических симптомов. В целом, эхинококкозу головного мозга свойственно псевдоопухолевое течение с явлениями застоя на глазном дне и нарушениями мозгового кровообращения в результате механического давления паразитарной кисты (С.К. Акшулаков, Е.Т. Махамбетов, 2000). Дополнительные сложности создает схожесть клинической картины эхинококкоза головного мозга с некоторыми другими объемными внутричерепными процессами ().
Единственным радикальным методом лечения является хирургическое удаление эхинококковой кисты головного мозга (Krajewski R, Stelmasiak Z, 1991). Поздняя обращаемость, связанная с несвоевременной диагностикой, значительно ухудшает прогноз и исход хирургического лечения, а также темпы и полноту регресса неврологической симптоматики.
Несмотря на значительный прогресс в диагностике и хирургическом лечении эхинококкоза мозга результаты лечения не улучшаются. Процент рецидивов заболевания все еще остается высоким и по данным разных авторов составляет 10,5-43% (Е.Т. Махамбетов, 2000 г.).
Вследствие того, что заболеванию наиболее подвержен детский возраст (), поздняя диагностика и неэффективное хирургическое лечение может оказать влияние на состояние здоровья и трудоспособность больного, перенесшего в прошлом эхинококкэктомию головного мозга.
Цель исследования: изучить и конкретизировать диагностические признаки течения эхинококкоза головного мозга, проанализировать методы и результаты хирургического лечения.
Научная новизна работы состоит в том, что на основании комплексного клинико-диагностического исследования установлены критерии, позволяющие произвести достоверную предоперационную диагностику эхинококкоза головного мозга. Разработан дифференцированный подход к хирургическому лечению эхинококкоза головного мозга методом гидравлического выталкивания в зависимости от локализации, размеров, возраста пациента и фазы течения заболевания.
Выводы:
1. Клиническая картина эхинококкоза головного мозга состоит из общемозгового и очагового симптомокмплексов. При этом на ранних стадиях заболевания превалирует общемозговая симптоматика, а позднее, по мере нарастания декомпенсации, происходит манифестация локальных неврологических симптомов.
2. Выраженность клинических проявлений эхинококкоза головного мозга зависит от возраста больного, стадии заболевания и локализации паразитарной кисты. У детей, в связи с большими компенсаторными возможностями черепной коробки, развитие клинической картины имеет менее выраженную динамику, чем у взрослых.
3. Клиническая картина эхинококкоза головного мозга соответствует современной концепции фазного развития проявлений внутричерепного новообразования.
4. Наиболее информативными методами диагностики являются компьютерная томография и магнитно-резонансная томография головы, позволяющие достоверно диагностировать эхинококковую кисту головного мозга. При этом гидатида представляет собой округлое образование, равномерной низкой плотности, с четкими ровными контурами и, как правило, не вызывающая перифокальный или разлитой отек мозга.
5. Методом выбора хирургического лечения эхинококкоза головного мозга является метод гидравлического выталкивания, который в 61 случаях (71%) позволил произвести тотальное удаление гидатиды без повреждения её оболочки, что предотвратило обсеменение окружающих тканей головного мозга.
6. На исход хирургического лечения эхинококкоза головного мозга оказывает влияние стадия заболевания на момент поступления пациента в клинику, а также размеры, количество и локализация гидатиды и факт интраоперационного разрыва оболочки кисты.
7. Рецидивы эхинококкоза головного мозга у прооперированных больных в 5 из 6 случаев (83,3%) были связаны с фактом повреждения стенки эхинококковой кист в момент первичного хирургического вмешательства.