Periods of infectious diseases. Period of residual effects: muscle hypotonia, residual skeletal changes
Contents of the article
The period of convalescence represents the fourth period of burn disease.
Restoring the skin with surgical operations or independent epithelization of superficial burn wounds for many patients does not mean that they have fully recovered. Almost all patients who have been diagnosed with burn disease based on the area and depth of burn wounds are indicated for sanatorium-resort rehabilitation. From 15 to 40% of victims of deep burns require reconstructive operations (surgical rehabilitation) due to the consequences of thermal injury and dysfunction of the musculoskeletal system (contractures, trophic ulcers, pathological scars, especially keloids, cosmetic defects, etc.).
Rehabilitation is a system of conservative and surgical measures aimed at fully or partially restoring the function of individual organs and systems of the human body and returning him to work or social activities.
The rehabilitation period for patients with burns depends on the severity of the burn disease and ranges from 1 to 5 years in adults, and until the end of their growth period in children.
Clinic for the period of convalescence of burn disease
The general condition of the patients is satisfactory. Wounds on skin completely healed. Body temperature is normal. Sleep is restored and appetite increases. Patients quickly gain body weight (processes of absorption in the body prevail over processes of elimination). The color of post-burn skin areas varies from pink and red to cyanotic. In their place, dermatoses, inflammation, pyoderma may develop, and hypertrophic and keloid scars may form. Scar deformities, limitations in skin function, and aesthetic defects occur. The victims are bothered by paresthesia and itching, which gives them a feeling of discomfort, inferiority, neurotic reactions and sometimes suicidal tendencies.In patients with a satisfactory course of burn disease and relatively favorable aesthetic and functional consequences, their mood significantly improves. They are willing to make contact, become more active, and begin to engage in intensive physical therapy. However, during the recovery period, 2/3 of patients experience irritability and rapid physical fatigue. They experience various inflammatory, dystrophic and other changes in the kidneys, liver, cardiovascular and respiratory systems (nephritis, pyelitis, myocardial dystrophy, decreased vital capacity, bronchopneumonia, chronic gastritis, cirrhosis of the liver). Functional changes occur in natural resistance and immunological reactivity, as well as in the intensity of autoimmune reactions. Changes in internal organs and systems are compensatory or subcompensatory in nature, and their clinical symptoms are not always sufficiently pronounced. To determine the full picture of these disorders, it is sometimes necessary to conduct special laboratory tests. Most patients have disorders in internal organs within 12-18 months. after healing, wounds are significantly reduced and can be eliminated with properly carried out rehabilitation.
During a laboratory examination of victims who have suffered deep extensive burns, with a normal content of total protein in the blood serum, hypoalbuminemia and an increase in the concentration of γ-globulins are detected. A general blood test reveals eosinophilia, a moderate decrease in the number of segmented neutrophils, lymphocytosis, and increased ESR.
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Recovery - special condition of the body, occurring after the end of any disease process and continuing until normal nutrition and activity of all organs are completely restored. In mild diseases, this condition occurs completely unnoticed, almost coinciding with the end of the disease. However, the longer the disease lasts and the more important for the body the disturbances in activity it causes various organs, the more important the recovery period becomes.
Features of the recovery process
Recovering woman (photo by Monty)
Recovery is characterized, first of all, by different frequency. For example, the consequences that occur from heavy blood loss in the peripheral areas of the body (extremities) are eliminated relatively easily and quickly, while a stroke causes a recovery period that often lasts several months. Recovery from a relatively dangerous illness, such as lobar pneumonia, sometimes occurs in a few days, while a relatively harmless catarrh of the stomach may require several months to restore normal digestion and nutrition. Happy ending typical shape typhoid fever, a healthy state occurs after 2-3 weeks. After surgical illnesses or major operations, the recovery period - often very long - is determined by the course of those local processes that underlie the disease process or operation.
Private measures and instructions that are needed for those recovering regarding their diet, furnishings, clothing, activities, etc., for various diseases are considered in a private description of these diseases. Here it is necessary to dwell only on the social and hygienic significance that represents the contingent of those recovering in a given population or in a given social group.
Recovery in social settings
Those who are recovering, due to the state of their health, cannot yet return to their usual way of life, but no longer require the forms of care that were applied to them during the period of illness. Those recovering from many contagious diseases retain the ability to transmit the infection to healthy people for quite a long time, such as those recovering from smallpox, measles, scarlet fever, and therefore, like the sick, they must be isolated for some time from the healthy and other convalescents. Caring for those in recovery is carried out in various ways. In families, during home treatment, the doctor examining the patient continues to monitor the progress of recovery. In hospitals, they often detain convalescents on a general hospital basis until they fully regain strength and health, and sometimes they are transferred to special wards with special staff and special organization.
Institutional basis of the process
In some countries, very special institutions are common, designated specifically for the placement of convalescents. Special institutions for convalescents, which are not connected with hospitals, originate from France, where the first such institution, established on a charitable basis, arose back in 1640 for women and girls leaving the Hotel-Dieu hospital. In 1855, public convalescent homes arose in Paris, namely Asyle de Vincenne for men (with 525 beds) and Asyle de Vesiret for women (350 beds). At the end of the 19th century, such shelters were common in England, where there were more than 150 of them, together with private ones. In the Russian Empire, there have long been some methods of caring for convalescents, the so-called “weak teams” in the troops, in essence, shelters for convalescents.
The functions of organs and body systems that were disrupted during three periods of the disease gradually return to normal. However, dysfunction of the heart, liver, kidneys and other organs can be observed 2 to 4 years after the injury. Patients who have suffered a burn disease are subject to dispensary observation.
Issues of blood transfusion, clinical picture and treatment of blood transfusion complications.
The history of blood transfusion goes back more than 3 centuries. Attempts to transfuse blood into humans since the 17th century have most often ended in failure. A favorable outcome during this period could have been purely coincidental, since the issues of interaction between the blood of the donor and the recipient were not studied at that time. In 1901, the Austrian Karl Landsteiner established that, depending on the presence of isoantigens in erythrocytes and isoantibodies in plasma, all humanity can be divided into 3 groups. In 1907, the Czech J. Jansky supplemented Landsteiner’s data, identifying the 4th group, and created a classification of blood groups, accepted since 1921 as international.
Blood groups.
For the occurrence of hemolytic post-transfusion reactions and incompatibility between mother and fetus, what matters primarily is the antigenic structure of the erythrocyte. Antigens are protein substances that can cause the formation of antibodies in the body and react with them. In the human body, in addition to immune antibodies that are produced in response to an antigen, there are natural antibodies that exist from the moment of birth and are caused by genetic characteristics inherited from parents. An example of natural antibodies are group isoagglutinins a and b. They are specific and react with the corresponding antigens - agglutinogens A and B. The temperature optimum for the reaction is +15 - +25 degrees C. All humanity, depending on the content of antigens (agglutinogens) A and B in erythrocytes, is divided into 4 groups:
group – does not contain antigens;
group – contains agglutinogen A;
group – contains agglutinogen B;
group – contains agglutinogens A and B.
The blood of these groups, strictly depending on the presence or absence of group antigens A and B, which are called agglutinogens, contains group antibodies, which are otherwise called agglutinins (isoagglutinins, group agglutinins). The blood system remains stable in the absence of the same agglutinins and agglutinogens (antibodies and antigens) in it. In this case, their interaction does not occur, manifested by agglutination (gluing) and hemolysis (destruction) of red blood cells. Thus, based on the serological properties of red blood cells and plasma, 4 blood groups are distinguished.
group ab – there are no antigens (agglutinogens) in the blood.
group Ab – there are no antibodies and antigens of the same name in the blood.
group Ba - (agglutinins and agglutinogens).
group AB – there are no antibodies (agglutinins) in the blood.
The percentage of people with different blood groups in different places around the world is not the same. In the CIS countries it is approximately this:
O(I gr.) 34%; A(II gr.) 38%; B(III gr.) 21%; AB(IV gr.) 8%.
Rh factor.
In 1937, Landsteiner and Wiener discovered the Rh factor (Rh factor). During experiments on rabbit immunization with erythrocytes from a rhesus monkey (Makakus rhesus), a serum was obtained that agglutinated 85% of human erythrocyte samples, regardless of group affiliation. Thus, it was established that there is a substance of an antigenic nature in human erythrocysters, similar to that in rhesus monkeys. It is called the Rh factor. People who have this factor in their blood began to be designated as “Rh-positive”, those in whom it was not determined – “Rh-negative”. The Rh factor is found in the blood of about 85% of people and, unlike agglutinogens (antigens) A and B, as a rule, does not have natural antibodies. Antibodies against the Rh factor (anti-Rh) arise only as a result of sensitization of an Rh-negative (not having the Rh factor) person with red blood cells containing the Rh factor. Antibodies may also appear in the blood of an Rh-negative pregnant woman in response to an Rh-positive fetus. Rh incompatibility (Rh conflict) occurs in the event of repeated contact of a sensitized person with the Rh factor (blood transfusion, pregnancy).
There are many other antigens in the blood. They are designated as the MN, Kell, Duffy, Lewis, Lutheran, etc. systems. Severe posttransfusion complications and hemolytic disease are caused by them extremely rarely. Currently, antigens have been identified in leukocytes, platelets, and other protein structures with a total number of about 300 species.
We observed posthepatitis syndrome of varying severity in a small number of cases (0.9-5.5%) during all periods of the examination.
The most common dyskinesias of the gastrointestinal tract and biliary tract are observed, expressed either in a spastic state or (less often) in atony of these departments. A type of dyskinesia is caused by damage to the autonomic nervous system with a predominance of the tone of one of its parts - sympathetic or parasympathetic, which causes various clinical symptoms.
Along with dyskinesias, pancreatitis is also common. According to Theuer, the latter are also caused by damage to the pancreas by the hepatitis virus. A decrease in excretory enzymes by the pancreas may also be due to less entry of bile acids into the duodenum, which reduces the excretion of lipase and amylase.
Lesions of the gallbladder and bile ducts are observed, according to R.V. Zaitseva, N.P. Zhuravlev, very often, while Selmair et al. recorded damage to the gallbladder only in 1.5-2% of cases.
Our studies of the state of the biliary tract in convalescents showed that the frequency of their damage is directly dependent on the duration of convalescence. In the first three months, the highest frequency of detection of cholecystocholangitis is observed (42.4%); when examined after 3-6 and 6-12 months. from the onset of the disease, the frequency of detection of this pathology decreased significantly (18-21%), which allows us to consider these changes as manifestations of the underlying disease.
Changes in the kidneys are expressed in hematuria and albuminuria. However, the biopsy performed in these cases does not reveal an inflammatory process; there is only cellular infiltration of the glomeruli and interstitial edema. According to a number of authors, these changes disappear 1 year after the onset of clinical recovery.
To resolve the issue of the presence of an inflammatory process in the liver during the convalescence period, it is necessary definition enzymes with different intracellular localization, which, according to Wroblewski’s figurative expression, creates the possibility of performing a biochemical biopsy.
We studied a number of enzymes in 213 convalescents. From the statistical data it is clear that the frequency of pathological indicators of GDH was maximum in the period of early convalescence - on the eve of discharge, indicating an unfinished inflammatory process in the liver. Malate dehydrogenase (MDH) activity was often increased by 12 months of convalescence. Apparently, this fact, to a certain extent, can be used as an indicator of autoimmune processes leading to latent hemolysis (MDH - found in large quantities in red blood cells).
Thus, it is obvious that to assess the completeness of recovery, the determination of the following enzymes should be considered most suitable - GPT, GSHT, GLDG.
In most cases, posthepatitis hyperbilirubinemia is characterized by an increase in the level of bilirubin due to the predominance of its indirect fraction and is similar to Gilbert's hyperbilirubinemia. Teichmann, Schroder observed hyperbilirubinemia in 3.5% of cases. According to our data, in recent years the frequency of hyperbilirubinemia does not exceed 1% of cases.
Exacerbations viral hepatitis in most cases, they occur in the first months of convalescence, their frequency is from 1.0 to 10.0% of cases.
Exacerbations of the process may be accompanied by disorders of pigment metabolism and occur without jaundice.
According to our data, for all the years (12 years) of our dispensary observation the frequency of exacerbations does not exceed 5.3% of cases. At the same time, it is noteworthy that in the vast majority of cases, exacerbations are caused by a sharp violation of the regime. In 4.2% of exacerbations there were no changes in pigment metabolism.
Theuer also observed exacerbations in early period convalescence (up to 6 months). According to the author, they occur no more often than in 5% of cases.
According to some authors, exacerbations are directly related to the nature of the therapy used in the acute period of the disease. Thus, among those treated with prednisolone, the named authors observed exacerbations in 14.2% of cases, and among those who did not receive hormonal therapy - in 5.2%. Our comparison of two groups of convalescents - those treated and not treated with corticosteroids (suffering a moderate form of the disease) - allowed us to come to the conclusion that prednisolone therapy rather improves well-being, helps eliminate intoxication, normalize pigment metabolism, but does not accelerate recovery. The frequency of exacerbations in convalescents of viral hepatitis who received and did not receive prednisolone during the acute period of the disease did not differ significantly from each other.
The genesis of exacerbations in most cases can be considered as an exacerbation of a dormant process.
It should be noted that only a systematic clinical and biochemical examination, and in some cases supplemented by a puncture biopsy of the liver, allows us to resolve the question of whether secondary disease exacerbation or reinfection. When analyzing the reasons for the unsmooth course of convalescence of viral hepatitis, we found that in children aged 7-11 years, post-hepatitis manifestations arise due to a sharp violation of the regime.
The variant of the disease also has a significant impact on the course of the convalescence period: for example, after anicteric viral hepatitis, the frequency of exacerbations is higher (6%) than after icteric hepatitis (2%).
During the process of convalescence, a gradual normalization of metabolism occurs. Thus, when studying the aminogram, it was found that the violation of the ratios of individual amino acids persists for 1 year. The most significant changes are observed in convalescents of moderate forms of viral hepatitis and are characterized by an increase in threonine and tyrosine, a decrease in histamine and glycine, although the total amount of amino acids does not exceed the physiological norm.
During the period of convalescence, significant disturbances in the autonomic and central parts of the nervous system are still recorded.
During this period, it is very important to decide on the choice of the most optimal period for revaccination and vaccination.
In accordance with the task, our clinic studied the effect of preventive vaccinations on the course of the convalescence period through clinical and biochemical examination of children with simultaneous analysis of the nature of the immunological response to vaccination. As a result of the studies, it was found that the response immunological reaction in children vaccinated 6-12 months after discharge from the clinic, it turns out to be quite sufficient in relation to the development of a protective titer to diphtheria, tetanus toxins and less in relation to pertussis antigen.
When vaccination against smallpox was carried out, the presence of a sufficient titer of anti-smallpox antibodies was established in 70% of cases.
Vaccination of convalescents should be considered indicated 10 months after their discharge from the hospital, subject to clinical well-being and the presence of normal biochemical parameters, indicating the elimination of the inflammatory process in the liver.
