Abstract. The continuous wave-like morbidity increasing of coronavirus disease in 2019 (COVID-19), the emergence of different strains of the virus has contributed to the search for new ways in diagnostic algorithms and methods of treatment of such patients. Expert opinion of the International Society of Thrombosis and Haemostasis on the predictors of adverse COVID-19 encourages the search for modern ways to determine the degree of coagulopathy. Determination of prothrombin time clearance, D-dimer and platelet count in patients, whom was performed surgery, is one way to stratify the risk of venous thromboembolism. The results of surgical treatment of 504 patients in the surgical center of Lviv Emergency Medical Hospital for the 2019-2021 were analyzed. Slightly dominated by man – 52.7%. The age of patients ranged from 21 to 85 years (mean – 62.1±21.2). As a result of the scientific study, 36 (7.14%) patients operated on with abdominal pathology and confirmed diagnosis of COVID-19 were analyzed in detail. 27 (23.1%) patients were
in the intensive care unit, 14 of them (51.8%) with invasive lung ventilation – 11 (78.6%), the average bed-day in intensive care was 7.2 days. 14 (38.9%) patients died, and autopsies were performed in 13 (92.8%). Cause of death: multiple organ failure, pulmonary embolism, septic complications. Introduction. The continuous wave-like morbidity increasing of coronavirus disease in 2019 (COVID-19), the emergence of different strains of the virus has contributed to the search for new ways in diagnostic algorithms and methods of treatment of such patients. Since December 2019, more than 240 million patients and 4.8 million deaths caused by coronavirus SARS-CoV-2 have been registered, a third of whom, according to many authors, have been diagnosed with thrombosis in various locations. The development of coagulopathy and ICE syndrome in coronavirus-infected surgical patients is a special problem, because cytokine distress, hypoxia, endothelin dysfunction, hypercoagulation, thrombosis are potentiated [1,3,6,8]. Expert opinion of the International Society of Thrombosis and Haemostasis (ISTH) on the predictors of adverse COVID-19 encourages the search for modern ways to determine the degree of coagulopathy. Determination of prothrombin time clearance, D-dimer and platelet count in patients, whom was performed surgery, is one way to stratify the risk of venous thromboembolism (VT). And some publications on septic coagulopathy[2,3,5,6,7] additional monitoring of fibrinogen levels, especially their reduction, may be useful in calculating thrombosis risks in surgical patients with coronavirus disease. The aim of the study was to establish the diagnostic value of thrombosis markers in patients with acute abdominal surgical pathology infected coronavirus and to predict the course of the disease. The data of the study 1494 autopsies conducted in our clinic from 1990 to 2000 are noteworthy, as we note a certain change in the ratio of the causes of death of patients in a surgical hospital. Thus, during the SARS-CoV-2 pandemic, the predominant cause of death in patients with acute abdominal surgical pathology was respiratory failure and thromboembolic complications. However it should be noted that some caution of doctors who formulated the final diagnosis because more than half of the dead, sometimes unreasonably, in the concomitant diagnosis indicated pulmonary embolism. Taking into account the opinion of ISTH experts, we have studied certain indicators of coagulopathy during the postoperative period and created an algorithm for the
management of patients with COVID-19. The D-dimers dynamics, total fibrinogen, prothrombin time and platelet count were evaluated and subjected to multifactorial analysis by multiple regression. Thus, the significant difference between the groups of recovered and dead was: for D-dimers – an increasing of 3.4 times (p-0.193), for prothrombin time – an increasing of 2.3 times (p-0.454), for fibrinogen – a decreasing of 2.1 time (0.491) and for platelets – a decreasing of 1.7 times (p-0.567). According the studied data, the algorithm for predicting the unresponsive course of the postoperative period in patients with acute surgical abdominal pathology infected with coronavirus type SARS-CoV-2 was modeled. The risk group for fatal thromboembolic complications should include patients with significantly elevated D-dimer, prolonged thromboplastin time, platelet count <100*109/1 and fibrinogen < 2 g/l. In this case, in our opinion, it is advisable to use more aggressive therapeutic regimens, namely: observation in the intensive care unit, daily monitoring of coagulopathy, the use of therapeutic doses of anticoagulants and possible administration of blood products. Keywords: COVID-19, abdominal surgical pathology, predictors.

UDC 616.366-003.7:616-007.272]-07-08 

Abstract. Background. Gallstone ileus is a pathology characterized by a variety of clinical manifestations and types of the course. Therefore, it is difficult in the diagnostic and therapeutic aspect and leads to unsatisfactory treatment results. The aim of the work is to find out the features of diagnosis and treatment of patients with gallstone ileus. Materials and methods. A retrospective analysis was performed of 51 medical records of inpatients with gallstone
obstruction operated in the clinic from 1990 to 2020. Women aged 61 to 85 (median of 74.20 ± 12.95) years predominated — 44 (86.3 %). Most patients (81 %) had concomitant diseases, which in combination with gallstone ileus caused high surgical risk: coronary heart disease — 26 (51 %), essential hypertension — 11 (21.6 %), diabetes mellitus — 3 (5.9 %), obesity — 1 (2 %). Results. During the clinical, laboratory and instrumental examinations, the
following preliminary diagnoses were made, for which surgical treatment was performed: acute adhesive intestinal obstruction — 29 (56.9 %), gallstone ileus — 9 (17.6 %), acute bowel obstruction — 4 (7.8 %), acute mesenteric circulatory failure — 4 (7.8 %), acute cholecystitis — 3 (5.9 %), hernia — 1 (1.9 %), peritonitis — 1 (1.9 %). Gallstone obstruction was detected at different levels: in the duodenum — in 3 (5.9 %) patients, jejunum — in 17 (33.3 %), ileum — in 23 (45.1 %) and colon — 8 (15.7 %) patients. The cause of stones in the lumen of the digestive tract was cholecystoduodenal fistula — in 48 (94.1 %) and choledochoduodenal fistula — in 3 (5.9 %) patients. Diagnosis of biliary fistulas was performed during postoperative radiological and endoscopic examination. The scope of surgery was aimed at eliminating acute intestinal obstruction; enterotomy was performed 5–10 cm distal to the
site of obstruction with lithoextraction. In one patient with areas of focal necrosis at the site of stone entrapment, a loop of the small intestine was resected with entero-enterostomy “side-by-side”. In case of duodenal obstruction, lithoextraction was performed through gastrotomy. In the perioperative period, 43 (84.3 %) patients received antibiotic prophylaxis using cephalosporines, fluoroquinolones and metronidazole. Purulent-septic complications in
the postoperative period developed in 9 (17.6 %) patients: suppuration of the postoperative wound in 6, infiltrate of the abdominal cavity in 1 and bronchopneumonia in 2. Two patients died, postoperative mortality was 3.9 %. Conclusions. Gallstone intestinal obstruction is difficult to diagnose due to a variety of clinical manifestations and course, and, accordingly, it is accompanied by frequent complications and high mortality. Surgical treatment should
eliminate intestinal obstruction in conditions of high surgical risk without repair of biliodigestive fistula. Early detection and determination of indications for planned surgical sanitation of the biliary tract is a reliable way to prevent gallstone ileus.
Keywords: acute intestinal obstruction; gallstone; biliodigestive fistula; aerobilia; enterotomy; lithoextraction

УДК 616.831-005.1-039.76-085.81/.84

РЕЗЮМЕ. Проблема відновлення пацієнтів після перенесеного геморагічного інсульту є однією із актуальних питань сучасної реабілітації. Згідно зі статистичними даними, у 48 % хворих, які перенесли інсульт, розвиваються інвалідизуючі геміпарези, у 30 % – психоорганічні синдроми та лише 10–15 % пацієнтів повертаються до праці. Це свідчить про актуальність даної проблеми та необхідність пошуку шляхів удосконалення та оптимізації відновного процесу в даної групи хворих. Одним із факторів порушень мозкового кровообігу є дисбаланс нуклеїнового гомеостазу, він корелює з тяжкістю захворювання, що дозволяє оцінити динаміку вогнищевої та загальномозкової симптоматики.
Мета роботи – дослідження ефективності немедикаментозних засобів лікування у реабілітації пацієнтів з наслідками порушення мозкового кровообігу у відновному періоді (3–10 місяць після крововиливу). Порівняти отримані результати із даними, отриманими після проведеної класичної реабілітації у пацієнтів контрольної групи.
Матеріал і методи. В роботі досліджено ефективність реабілітаційних заходів із застосуванням немедикаментозних методів лікування: гірудотерапії, апітерапії, рефлексотерапії та мануальної терапії у 66 хворих із наслідками перенесеного геморагічного інсульту в пізньому відновному періоді. Для об’єктивізації даних дослідження використано оціночні шкали, які застосовували на початку лікування, через один та через три місяці після реабілі- тації. Оцінку неврологічного статусу проводили за шкалою інсульту національного інституту здоров’я (NIHSS), ступінь підвищення тонусу м’язів – за модифікованою шкалою спастичності Ашфорта. Динаміку функціонального стану пацієнтів оцінювали за шкалою Ренкіна, індексом активності у щоденному житті Бартел, когнітивні функції за шкалою Mini-Mental State Examination (MMSE), психоемоційний стан оцінювався за шкалами Бека та Монтгомері – Асберг. У роботі визначено рівень нуклеїнових кислот (ДНК, РНК) і активність кислих і лужних нуклеаз у сироватці крові на початку та в кінці лікування. Ці результати порівнювали з результатами реабілітації пацієнтів контрольної групи (n=50), які отримували класичну схему реабілітації.
Результати. Встановлено вірогідне покращення стану пацієнтів з наслідками перенесеного геморагічного інсульту яке проявлялося в відновленні показників функціонування за шкалою Ренкіна на 14 % після першого і 29 % після третього місяців лікування, р<0,05. Покращення за індексом Бартела становило 9 % після першого і 20 % після третього місяців відповідно, р<0,05. Зменшення спастичності м'язів за шкалою Ашворт становило 12 %, когнітивні функції відновились на 19 % піля проведеного лікування в порівнянні із станом на початку лікування. Психоемоційний стан покращився на 44 % і 40 %, р<0,05 (за шкалою MADRS та шкалою Бека) після проведеної реабілітації в порівнянні із станом на початку лікування відповідно. Після проведеної реабілітації спостерігали зменшення рівня ДНК та збільшення кількості РНК у сироватці крові пацієнтів. Зміни активності нуклеаз та відповідних коефіцієнтів їх взаємовідношень (зменшення рівня ДНК-ази I та РНК- ази II, зростання РНК – ази I та ДНК –
ази II, зростання коефіцієнтів К1 і К3, зменшення рівня К2). Покращення даних показників в основній групі пацієнтів було достовірно кращим, ніж в групі порівняння.
Висновки. Призначення реабілітаційної програми із застосуванням немедикаментозних засобів лікування у пацієнтів з наслідками перенесеного геморагічного інсульту у пізньому відновному періоді покращує функціональні показники загального стану пацієнтів, зменшує спастичність уражених м’язів, та інвалідизацію, підвищує показники активності та психоемоційний стан пацієнтів. Зміни нуклеїнового гомеостазу свідчать про зменшення процесів розпаду та аутолізу мозкових клітин і активацію відновних процесів, порівняно з контрольною групою.
КЛЮЧОВІ СЛОВА: реабілітація; гірудотерапія; апітерапія; рефлексотерапія; мануальна терапія; ДНК; РНК; нуклеази; геморагічний інсульт.

Abstract. Rehabilitation of patients following an acute myocardial infarction remains one of the most urgent tasks of modern cardiology. Cardiac rehabilitation programs are aimed not only at improving the functioning of the cardiovascular system but also at ensuring the mental health of patients, restoring their working capacity, and returning to a full-quality life as soon as possible. Patients receive many benefits of cardiac rehabilitation from physical training. The main type of physical exercise in patients with cardiovascular diseases is aerobic training, which increases maximal oxygen consumption and improves cardiorespiratory endurance. The dosed training method is the basis of the development of the patient's functional adaptation to physical exertion in cardiovascular diseases. The objective was to develop and test the effectiveness of the physical therapy method proposed by the authors for the recovery of patients with acute myocardial infarction after stenting. Material and methods: clinical (standard) examination and interview of the patient, medical history, blood pressure (BP) and heart rate (HR) measurement, pulse oximetry with saturation (SpO2) determination, orthostatic test, 10-meter walk test (10MWT), the Timed Up and Go test (TUG), the 6 Minute Walk Test (6MWT). 16 patients were enrolled in the study which lasted 5 weeks. Sessions according to the developed methodology of physical therapy were conducted with each patient for 12 days. Inclusion criteria: age between 50-80 years old, medical diagnosis: myocardial infarction, after stenting, no contraindications to cardiac rehabilitation. The effectiveness of the developed method of physical therapy for the recovery of patients with acute myocardial infarction after stenting was assessed. Changes in the performance of 10MWT, 6MWT, and TUG tests indicated improved adaptation and tolerance of the respiratory and cardiovascular systems to exercise, as well as normalization of blood pressure, heart rate, and SpO2. Conclusions. Physical exercises, according to the developed program of physical therapy, improve the general physical condition of patients, increase their functional capabilities, improve indicators of cardiovascular and respiratory system and have a positive effect on life quality. The study confirmed the importance of physical therapy in the recovery of patients with acute myocardial infarction after stenting.

Keywords:
myocardial infarction, physical therapy, cardiac rehabilitation

Abstract.

Introduction. Functional capacity is important parameter of activity of a person. It can be assessed with different methods, including interviewing, walk tests, cardiopulmonary exercise testing. According to the recommendations of the European Society of Cardiology, the assessment of functional capacity is an important step in the perioperative management of a patient with concomitant cardiovascular pathology during non-cardiac surgery. Purpose of our study was to implement assessing of functional capacity in clinical practice, including perioperative management of patients. And also, to compare the practical value of self-reported methods of assessing functional capacity and exercise testing. Materials and methods. 15 healthy men aged 33±5.4 years and 172 patients with documented pathology of the cardiovascular system aged 65±2.8 years were included in the study, among them 51% were male. We compared the value of different methods and the expediency of assessing the functional capacity of a patient with concomitant pathology of the cardiovascular system before planned non-cardiac surgery. Results. All healthy individuals gave a positive answer to the question about ability to climb two flights of stairs. The average Duke Activity Status Index score was 52.47±5.96, which corresponded to the calculated value of METs 9.19±0.73. During cardiopulmonary exercise testing, the average value of VO₂max in these individuals was 47.56±11.34 mL/(kg·min). A direct strong correlation between Duke Activity Status Index values and VO₂max was established (r=0.91, р˂0.01). 36 patients (21%) reported inability to climb two flights of stairs added. The average DASI in these persons was 12.84±4.38 and the level of NTproBNP was 1116±75. On the contrary in the rest of the patients the DASI was 28.18±7.72 and NTproBNP 302±42 with statistically significant difference (p˂0.01). The dynamics of troponins in the examined subjects did not show any increase in the postoperative period. The values of the EF in patients reported inability to climb two flights were lower by 9.78% compared with others (56.57±12.34% and 62.71±6.35%, p˂0.01). The average number of days spent in the hospital was 22 in patients with inability to climb two flights and 12 in the rest. 32 patients (19%) died, 28 deceased belonged to the group with inability to climb two flights of stairs. The average time of death was 29.86 days. Correlation analysis revealed a direct relationship of average strength between the Duke Activity Status Index and EF (0.42, p 0.007), an inverse relationship of average strength between the Duke Activity Status Index and NTproBNP (-0.42, p=0.01) and the number of days spent in a hospital (-0.39, p=0.005). In conclusion we found that healthy men with an active lifestyle have higher average VO₂max parameters and confirmed that the VO₂max obtained during the cardiopulmonary exercise testing was comparable to questionnaire methods for assessing functional capacity. One fifth of patients with confirmed cardiovascular pathology self-reported inability to climb two flights of stairs. These individuals had a lower EF, a higher concentration of NTproBNP, a longer stay in the hospital, and significantly higher mortality. the Duke Activity Status Index correlates with left ventricular systolic function and NTproBNP level.

Keywords: noncardiac surgery, concomitant cardiovascular pathology, perioperative assessment, functional capacity