Method for modeling autoimmune oophoritis. Medical information, Tomsk
That year the army lost an excellent officer, but medicine was an undeniable winner. Yesterday's schoolboy Vladimir Tkachev wanted to become a military man, but he was unable to enroll in the specialty he liked. But a friend suggested taking exams with him at Tomsk medical school to the Faculty of Medicine. And he, without especially thinking about why he needed it, agreed.
The competition for “doctor” was considerable, but this was not an obstacle, and both were enrolled. Only the first one dreamed of “healing people”, the second one came here for company. But how often His Majesty chance reshapes a person’s fate, pushing him in the right direction! There is no doubt that in a different scenario, and in a different field, Vladimir Nikolaevich Tkachev would also have achieved professional heights, because he belongs to that blessed galaxy of people who, no matter what they undertake, do it well. That's the character. But, thank God, he came to medicine, and one day the spontaneous decision he made turned out to be very accurate.
Suddenly, he became fascinated by his studies, and what was so far from his desires yesterday became decisive. Future profession was already declaring itself as a vocation, growing into a business without which it was impossible to imagine further life. I wanted to know more - I started studying in a scientific circle. Around the third or fourth year, he firmly decided that his specialization was obstetrics and gynecology. A serious and inquisitive student then attracted the attention of teacher Irina Evtushenko, now professor, head of the department of obstetrics and gynecology of Siberian State Medical University.
“The classes were held in the first maternity hospital, the group was new to me,” recalls Irina Dmitrievna. - When discussing the topic, one of the students asked several questions; it was felt how deeply he knew the material and how he wanted to find an answer to something that was still unknown to him. This was Vladimir Tkachev. He always took his studies very seriously, and that earned him respect.
By the way, the habit of studying has remained to this day, although today Vladimir Nikolaevich is capable of the most complex operations, professionally he has achieved a lot. But I will refer once again to the opinion of Irina Dmitrievna, “he always wants more.” When he worked in an obstetrics clinic, they also said about him that “he can do everything,” and he was highly valued as a specialist. But he set other, more ambitious goals for himself - to operate more. Irina Yevtushenko, by that time already the head of the department, decided to transfer Tkachev to the gynecology clinic, where they mastered endoscopic operations, and where he could already devote himself entirely to surgery. Why did you choose her? He answers simply and briefly: “ I always wanted and knew that I would be a surgeon" Colleagues note that even the first operations performed by Tkachev confirmed how much these hands can do.
Once upon a time, the Roman philosopher and physician Cornelius noted that “the effect of surgery among the branches of medicine is the most obvious.” Yes, the successes of surgeons are much more noticeable, more visible, perhaps, than the achievements of other specialists, but defeats, if they happen in a battle with the disease, are instantaneous. And no one is safe from them. How much you need to know and how much you need to be able to do in order to still win at the operating table at a crucial, difficult and dangerous moment. Thinking like a doctor, acting like a doctor, learning new things all your life, sacrificing a lot in the name of it - that’s what, in my opinion, this profession is. Besides everything it's still hard physical work, and also poorly paid, which is extremely unfair. In the Hippocratic Oath, which health officials and our journalistic brethren, who expose “bad doctors,” are so fond of remembering, it is not appropriate and inappropriate to remember, there is not a word about the fact that a doctor is obliged to live in poverty. Today the situation surrounding surgery is almost tragic. In any case, this is how Vladimir Naidenkin, deputy, characterizes her. the chief physician of the Siberian State Medical University clinics and a highly qualified surgeon himself. It may be said emotionally, but in many respects it is probably true, which is confirmed by statistics. Today everyone knows that there is a shortage of doctors in various specialties in Russia, the biggest shortage of personnel is in surgery.
“To become a real professional in our business, you need to work for 15 years, and study, study, study... Spare no effort or time,” says Vladimir Ivanovich. “And that would be normal, because people entrust their lives to us.” If only there were adequate material rewards to some extent. And so... A young doctor has a salary of six thousand, usually there is no housing, no benefits, but he has a family that he is obliged to take care of. Nowadays, among senior students and university graduates, rarely do anyone choose surgery. Although, of course, there are talented young people, those who, in spite of everything, devote themselves to surgery. Then you are glad that there is someone to pass on your experience to, there will be a change. And they want to say: it’s happiness, real luck, when you can learn from surgeons like Tkachev!
He defines the secret of his colleague’s professional credo in one short but succinct phrase: Tkachev is a real, correct doctor. Still, I ask you to express this verbally in more detail. “And now I’ll show you the summary,” Vladimir Ivanovich responds to the request. - You see, in a year Tkachev performed more than 700 operations, many of them related to the so-called high technologies. But it’s one thing to operate, another thing to get out; complications can only be prevented during a period of diagnostic observation. And so, after standing for 5-6 hours operating table, he then in mandatory monitors the patient’s condition and maintains constant contact with the attending physician. He comes to the clinic in the evening, on Saturday and Sunday... And such control is exercised not only over his patients, he is also the head of the clinic, which means he is in charge of everything that happens there. Responsible and reliable, you can always rely on him, he will never let you down. I would also note one more feature of his. What can I say, he is a wonderful surgeon, but absolutely devoid of any snobbery! He himself is happy to advise his colleagues, but he can also ask them for advice. By the way, he has a wonderful team at his clinic, and he is also a team man.”
About the well-coordinated and professional team in the gynecology clinic, including not only surgeons and doctors, but also middle and junior medical staff, I had to hear more than once. And the highest praise seemed to be the words spoken by the chief physician of the Siberian State Medical University clinics, Vitaly Shevelev. In my opinion, it is worth a lot when a leader medical institution, who has to be very careful about spending money (there is never enough of it), states: “ I don’t mind the money for this clinic; I know it will be spent wisely. There's a payoff there" And he lists what he puts into it: they set the highest goals for themselves, actively implement advanced ideas and technologies, keep abreast of everyone modern achievements, preference is given to organ-preserving minimally invasive surgery. “Of course, this is a considerable merit of Vladimir Nikolaevich Tkachev, both as the head of the clinic and as a surgeon of the highest qualifications,” adds Vitaly Mikhailovich. “He strives for excellence himself, and the entire team aims for this. In fact, the level that exists in Russia, and in many ways in the world, has been achieved in the clinic. Although there is something to strive for, and we will help with this. In addition, he is a wonderful person, non-conflict, reasonable, always responds to requests for help. You can calmly solve the most complex issues with him.”
Yes, the clinic today provides the full range of diagnostic, therapeutic and high-tech surgical care to your patients. Promising directions are being developed here. What was a miracle yesterday is almost commonplace today. Medicinal and scientific work is aimed at preserving a woman’s reproductive health, the ability to have children, and improving the quality of life at any age. And a lot of things succeed. Although other ambitious tasks immediately appear, for example, mastering robotics during operations. It is believed that this goal will be achieved. Moreover, the clinic’s specialists, working in close collaboration with the department’s staff, are quite capable of doing this. It's a matter of equipment. Current state team, personnel and scientific potential allow us to look into the future with optimism. And the inexhaustible desire of the head of the Tkachev clinic to learn plays a beneficial role in this process. It is also on his initiative that interesting conferences are held in real time, the country’s leading specialists are invited, with whom they operate together, which, of course, opens up new horizons and promotes the development of more techniques and techniques, ultimately - to better preserve the health of patients.
Over all these years, Vladimir Nikolaevich has never regretted his decision to enter medical school, although, like every person who works hard and fruitfully, there are times when fatigue accumulates. But this does not affect the clinic staff, especially the patients. What they call professional deformation, is unusual for him. He is always calm, confident, friendly, and if necessary, politely strict, which seems to be an absolutely correct tactic in communicating with patients. In moments of despair, women are especially susceptible to emotions that cannot always be contained. Someone cries, someone panics and says goodbye to life, someone hates this whole healthy world... But I myself witnessed when, after communicating with Vladimir Nikolaevich, women returned to the ward calm, smiled, called their relatives, discussed with their neighbors various important trifles. And the next day there was an operation, the outcome of which was now beyond any doubt. Only those who have experienced this themselves know how important it is to believe and hope at such a moment.
There are no trifles in the recovery process, at least that’s how things are set up in the gynecology clinic. There is a well-oiled mechanism at work here both in treatment and in ordinary everyday life. The atmosphere is benevolent, there is cleanliness and order all around, even where, in the words of a famous literary character, “ruin in our heads” begins. To the uninitiated, it seems that everything happens by itself.
“And that’s how it should be,” I’m sure. head nurse Tatyana Bugaeva. - We solve our problems in such a way that it does not affect patients in any way. Vladimir Nikolaevich and I came to our new positions in 2004. It seems to me that everything worked out for him right away, he knows how to organize things and assign everyone responsibilities. For all his goodwill, he has strict demands and does not tolerate sloppiness, because, first of all, he himself is very responsible. But you know, if official disputes happen, they pass without offense or tears. Our team is selected in such a way that people who love their work and value it remain here. I believe that this is also the merit of Vladimir Nikolaevich as a leader. After all, we are one team.
Here again about the team... The ability to form it was also noted by the clinic’s doctor, candidate of medical sciences, associate professor of the department of obstetrics and gynecology Sergei Nevostruev, who considers Vladimir Nikolaevich not only his teacher, but also the undisputed leader of operative surgery. And besides, in his opinion, Tkachev is also a talented teacher, because not only students and interns learn their skills from him, but already established doctors improve their skills. “Vladimir Nikolaevich has a special gift of openness,” says Sergei Alexandrovich. “He generously shares his accumulated experience with others, and this ability is not given to everyone.”
In any professional environment, the opinions of colleagues are important. Who else, if not them, can appreciate the results of what has been achieved.
“We trust Vladimir Nikolaevich unconditionally,” emphasizes Marina Petrova, Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology. - I say this not only as a colleague. I am grateful to him on a personal level, he helped my daughter not lose her child. When patients come to him, they are such reliable hands, you can be sure that he will do everything possible. He appears at the clinic early, at 7.30 he is already at his workplace, always aware of what is happening. Operates uniquely! It seems that there is no case that Tkachev cannot cope with. Not only is he not afraid to try new things, he strives for it. The most complex operations that are carried out in the leading central clinics of Russia, and those that are told to us at foreign congresses and symposiums - Vladimir Nikolaevich is fully proficient in all of this. The only thing left is the highest level - robotics. When we have such an opportunity, we will be the first to master it.
Vladimir Nikolaevich himself does not see anything special in his profession: work is like work, he says, but everywhere has its difficulties. He calls the operation that does not need to be performed the best, the most difficult situation is the one when it is already extremely clear that the disease has taken hold. Yes, over time, experience is gained that helps you always make quick, clear, specific decisions. But still, before each operation, he is collected and focused. The situation can turn out to be much more difficult than expected, and it is good to have a reliable team nearby.
“I can’t say that I came to an empty place and created a team,” emphasizes Vladimir Nikolaevich. - And before me, real professionals worked here, who had something to learn from. A surgeon cannot be alone, except to some extent... It is a big misconception to think that you know everything and can do everything. Each of us has our own teachers, and I do too, and I am very grateful to them for science. You can’t read a textbook and start doing something well - sharpening parts, building a house... But here we are talking about the most important thing in everyone’s life - health. And your own development and movement forward is possible if you have people working nearby who pick up your ideas and bring something of their own to them. This is exactly the case in our clinic. I am very interested in the experience of surgeons from other clinics, for example, how Viktor Ravilyevich Latypov works, because operations on adjacent organs add confidence and expand your field of activity. The surgeon needs to know more than what he himself is doing. This means that you must always study, choose the time for this, which is so lacking.
- The clinic is very closely connected with the department of obstetrics and gynecology, which is understandable: you are, in fact, one university...
- This is an excellent scientific school, a certain style of work, nurtured over the years, strong traditions that we are proud of, support and develop. And this is a great merit of the head of the department, Irina Dmitrievna Evtushenko. She is very kind to our veterans, who have achieved a lot in medicine and whose work we continue. In addition, we cannot afford to focus on one direction, because we teach students, and they must know not only the theory, but also see how this happens in practice. Training qualified personnel capable of effectively mastering innovative technologies is also our task.
- Today the clinic is not only one of the largest hospitals in the city and region, but in many areas you are pioneers, introducing the most Hi-tech treatment of non-operative and operative gynecology. But during the entire time of our conversation, I never once heard from you the usual complaints about poor funding, poor equipment...
- I can’t say that there are no problems at all; you always want more. But if we already lived through the 90s, when there was nothing at all... We make full use of the opportunities we have, and they are not bad. I must note with gratitude that we always find support from the chief physician of the clinics, Vitaly Mikhailovich Shevelev, he understands our requests and helps as much as he can. We also work in close cooperation with Vladimir Ivanovich Naidenkin, he is a surgeon himself and knows what we need. We dream about robotics and hope that we will soon use it too.
I also asked Vladimir Nikolaevich about his doctoral dissertation; his colleagues asked me to remind him that it was time... Several years ago he brilliantly defended his candidate’s thesis, and for a long time now he has had enough material for his doctoral dissertation. I promised to improve, because “he himself understands what is necessary,” which is what I report through the press.
I also want to tell you about a pleasant event for everyone who knows Vladimir Nikolaevich in the life of the surgeon Tkachev. Most recently in Sochi at the All-Russian Scientific and Practical Seminar “ Reproductive potential of Russia: versions and counter-versions“He was awarded a victory in the nomination “Mastery”. In a solemn ceremony, Vladimir Nikolaevich was presented with a commemorative figurine. His services at the Russian level were recognized by the professional community, and he was applauded by his colleagues gathered in the hall, who know the value of such an award. In his response, Vladimir Nikolaevich said that this award was not only for him, but for the entire clinic. These were not stock words, he sincerely thinks so. But he runs the clinic.
Nina MASKINA.
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480 rub. | 150 UAH | $7.5 ", MOUSEOFF, FGCOLOR, "#FFFFCC",BGCOLOR, "#393939");" onMouseOut="return nd();"> Dissertation - 480 RUR, delivery 10 minutes, around the clock, seven days a week and holidays
Nevostruev Sergey Alexandrovich. Morphofunctional state of the uterine appendages during chronic inflammation and complex treatment using mud extract (experimental clinical study): dissertation... Candidate of Medical Sciences: 14.00.01 / Nevostruev Sergey Aleksandrovich; [Place of defense: State educational institution of higher professional education "Siberian State Medical University"]. - Tomsk, 2004. - 176 p.: ill.
Introduction
CHAPTER 1. Literature review 12
1.1. Modern look on the problem of chronic inflammatory diseases of the uterine appendages 12
1.2. Morphological changes uterine appendages in inflammatory diseases 18
1.3. Principles of complex therapy of chronic inflammatory diseases of the uterine appendages 26
1.4. The importance of peloid therapy in the treatment of chronic inflammatory diseases of the uterine appendages 34
1.5. Characteristics of silt sulfide mud extract 38
1.6. Summary 43
CHAPTER 2. Material and research methods 45
2.1 Experimental part 48
2.2. Clinical part 52
2.3. Statistical processing of results 57
CHAPTER 3. Results of our own research
3.1. Morphological changes in the uterine appendages during chronic inflammation and their correction using silt sulfide mud extract 59
3.1.1. The course of experimental inflammation of the oviducts and ovaries in white rats 59
3.1.2. Morphology of the oviducts and ovaries of white rats during chronic inflammation caused by the introduction of a culture of Staphylococcus aureus 60
3.1.3. Morphology of the oviducts and ovaries of white rats during chronic inflammation caused by the introduction of a culture of Staphylococcus aureus after a course of abdominal sacral galvanization 76
3.1.4. Morphology of the oviducts and ovaries of white rats during chronic inflammation caused by the introduction of a culture of Staphylococcus aureus, after a course of abdominal-sacral electrophoresis of a 1% solution of silt sulfide mud extract 79
3.1.5. Morphology of oviducts and ovaries of white rats with chronic aseptic inflammation 86
3.1.6. Morphology of the oviducts and ovaries of white rats during chronic aseptic inflammation and a course of galvanization 96
3.1.7. Morphology of the oviducts and ovaries of white rats during chronic aseptic inflammation and after a course of abdominal-sacral electrophoresis of a 1% solution of silt sulfide mud extract 98
3.1.8. Indicators of a morphoquantitative study of the ovaries of white rats with experimental chronic inflammation and peloid physiotherapy 105
3.9. Summary
3.2. Influence complex treatment using electrophoresis of a 1% solution of silt sulfide mud extract on the clinical course and outcome of chronic inflammation of the uterine appendages 117
3.2.1. Clinical and laboratory characteristics of patients with chronic inflammatory diseases of the uterine appendages 117
3.2.2. Principles of complex treatment of patients with chronic inflammatory diseases of the uterine appendages 128
3.2.3. Dynamics of clinical and laboratory parameters depending on the complex therapy used. 130
3.2.4. Medical and social effectiveness of treatment of patients with CIDP using in combination therapeutic activities electrophoresis of a 1% solution of silt sulfide mud extract 135
3.2.5. Summary 143
CHAPTER 4. Discussion of results 146
References 163
Introduction to the work
Relevance of the problem. Chronic inflammatory diseases of the uterine appendages (CIID), despite advances in the development of new treatment methods and widespread introduction into practical medicine laparoscopy continue to be one of the pressing problems clinical practice[Kulakov V.I., 2001; Smetnik V.P., 2003; Henry-Suchet J., 2000]. Patients with inflammatory diseases of the uterine appendages make up 60-65% of all gynecological patients [Serov V.N., 2003; Risser W.L., 2002]. CIPV is a common cause of the syndrome pelvic pain, infertility, miscarriage, ectopic pregnancies and, as a consequence, large number surgical interventions [Veren J., 2002; Taylor R.C., 2001; Vilos G.A., 2002]. In this regard, improving the quality of treatment of patients with CIPV using complex, pathogenetically based approaches is of particular importance [Savelyeva G.M., 1997; Ross J.D., 2001].
In domestic and foreign literature there is numerous data on the pathomorphogenesis of chronic inflammation in the uterine appendages [Kovalsky G.B., 1996; Krasnopolsky V.I., 1998; Herschlag A., 2000; Furuya M., 2002]. However, the degree of involvement of the ovaries in the inflammatory process, the reversibility of morphological disorders in the uterine appendages against the background of CIDP, and the possibility of influencing reparative processes in the ovaries and fallopian tubes remain the subject of debate. There are single experimental studies devoted to this problem, but their results are often contradictory [Tikhonovskaya O.A., Logvinov S.V., 1999; Ordonez JL, 1999; Leese H.J., 2001].
In modern conditions, with CIPV, clear trends are visible, on the one hand, towards the use of minimally invasive methods operational diagnostics and treatment, on the other hand, to optimize measures aimed at rehabilitation of the functions of the organs of the female reproductive system [Strugatsky V.M., 2003; Cibula D., 2001; Ness R.B., 2002]. Achievements of recent years give reason to consider methods of physiotherapy as one of the most promising, taking into account their possibility of differentiated and targeted action on various parts of the pathogenesis of the disease, increasing adaptive capabilities with minimal risk of development adverse reactions[Bogolyubov V.M., 1998; Strugatsky V.M., 2002].
An undoubted reserve for optimizing the treatment of CIPM is the use of natural therapeutic muds and preparations obtained on their basis, which have the ability to regulate neurohumoral and immune processes, prevent and reduce dystrophic changes, stimulate the regeneration of cellular elements [Arkhipova L.V., 1995; Strugatsky V.M., 2003].
At the Institute of Petroleum Chemistry of the TSC SB RAS (Tomsk), a dry extract of silt sulfide mud was created, containing a complex of mineral salts, trace elements, organic matter with a wide range medicinal properties: anti-inflammatory, analgesic, hepatoprotective, etc. [Saratikov A.S., 2001; Vengerovsky A.I., 2002]. The use of the extract in acute inflammation of the uterine appendages has an anti-alterative, anti-exudative effect mainly due to the membrane-stabilizing antioxidant effect, expressed in a decrease in the concentration of lipid peroxidation products and catabolism of cell membrane receptors [Tikhonovskaya O.A., 1998, 1999, 2000].
At the same time, the mechanisms and patterns of the therapeutic effect of the silt sulfide mud extract in CIPM remain poorly understood.
Purpose of the study. To study the effect of silt sulfide mud extract on the morphofunctional state of the uterine appendages during chronic inflammation in an experiment and evaluate its clinical effectiveness.
Based on the above, the purpose and objectives of the study were formulated.
1. To develop models of chronic inflammation of the uterine appendages with a pronounced proliferative component.
2. To study, using the created models of chronic inflammation of the uterine appendages in experimental animals, the nature, dynamics and sequence of changes in various tissue elements: epithelium, connective tissue stroma, blood vessels, generative and endocrine elements. To evaluate, using models of chronic inflammation, the effect of electrophoresis of silt sulfide mud extract on the dynamics of the morphofunctional state of the oviducts and ovaries, the intensity of reparative processes, and to experimentally substantiate the possibility of using it in the complex treatment of chronic inflammation of the uterine appendages.
3. To develop a method of treating women with chronic inflammatory diseases of the uterine appendages, including peloid physiotherapy from the early stages after laparoscopy.
4. To analyze the effectiveness of the method of treating women with chronic inflammatory diseases of the uterine appendages according to immediate and long-term results.
Scientific novelty. Experimental models of chronic monocultural and aseptic inflammation of the ovaries and oviducts in white outbred sexually mature female rats have been developed. The experiment studied in detail the pathomorphogenesis in the uterine appendages during chronic inflammation, analyzed the role of various structural elements in the tissue mechanisms of inflammation of the oviducts and ovaries, and determined the sequence and nature of pathological disorders.
For the first time, it has been established that an extract of silt sulfide mud reduces inflammation-initiated atresia of the ovarian follicular apparatus, prevents the formation of fibrous-sclerotic adhesive changes and promotes regression fibrous tissue due to the activation of macrophages and fibroclasts and the normalization of the processes of collagenogenesis and collagenolysis.
The high efficiency of electrophoresis of a 1% solution of silt sulfide mud has been clinically proven as a pathogenetically substantiated component of the treatment of CIPM. For the first time in this pathology, the dynamics of hormonal function ovaries, functional activity of the fallopian tubes under the influence of peloid physiotherapy. The data obtained prove that electrophoresis of the extract carried out in early stages after laparoscopic organ-preserving interventions on the uterine appendages, it has a stimulating effect on ovarian function, increasing the secretion of estrogen and progesterone; restores functional activity fallopian tubes
Practical significance. The developed models make it possible to perform preclinical testing of new methods of treating CIPV.
As a result of the research, a pathogenetically substantiated method for the complex treatment of CIPM using an extract of silt sulfide mud was developed. The proposed method of treatment increases therapeutic effectiveness in terms of immediate and long-term results: it reduces the frequency of relapses, prevents the formation of pelvic pain syndrome, tubo-peritoneal infertility, and ectopic pregnancy.
The use of peloid physiotherapy in gynecological practice in non-resort conditions makes it possible to make the latter economically accessible broad layers population and has important socio-economic significance.
Provisions submitted for defense.
1. In the pathomorphogenesis of experimental chronic inflammation of the uterine appendages, regardless of phlogogen, there are similar changes, manifested by microcirculatory disorders, massive atresia of growing follicles, fibrous-sclerotic and adhesive processes. In the mechanism of tissue disorders important role plays a disturbance in the collagen synthesis-collagenolysis system.
2. The use of silt sulfide mud extract for chronic inflammation of the uterine appendages in the experiment limits the increase in atresia of the ovarian follicles, accelerates the regeneration of the oviduct mucosa, normalizes hemodynamics in the microvasculature, promotes reverse development fibrous-sclerotic and adhesive processes.
3. In the mechanism of the therapeutic effect of peloid therapy on the uterine appendages during chronic inflammation in the experiment, one of the leading places belongs to the activation of macrophages and fibroclasts and the normalization of the processes of collagenogenesis and collagenolysis, restoration of the ultrastructural organization of the hematofollicular barrier 4. Electrophoresis of a 1% solution of silt sulfide mud extract increases the effectiveness of complex treatment chronic inflammation of the uterine appendages in women according to immediate and long-term results.
Introduction into practice. The results of the study are used in the educational process at the Department of Obstetrics and Gynecology, Faculty of Medicine, Siberian State Medical University on the topic “Inflammatory diseases of the pelvic organs”; at the Department of Histology, Embryology and Cytology of Siberian State Medical University on the topic “Women’s reproductive system»; therapeutic activities gynecological clinic of Siberian State Medical University and "Center women's health» MADEZ LLC.
Approbation of work. The main results of the work were reported and discussed at the scientific and practical conference of students and graduate students "Youth Health - Health of the Nation" (Tomsk, 1998), the Final Conference "Tatiana's Day" based on the results of the Russian competition for the best scientific work of students in 1998 in the section " Medical Sciences" (Moscow, 1999), conferences " Contemporary issues fundamental and clinical medicine" (Tomsk, 1999), at the School of Young Researchers "Achievements of Molecular Biology and the Development of New Effective Methods for the Treatment of Human Diseases" (Moscow, 1999), VI and IX Russian National Congresses "Man and Medicine" ( Moscow, 1999, 2002), I, II, III International Congresses of Young Scientists and Specialists “Scientific Youth on the Threshold of the 21st Century” (Tomsk, 2000, 2001, 2002), Russian Scientific and Practical Conference “Topical Issues of Endoscopic Surgery in gynecology and obstetrics" (Tomsk, 2001), VI international scientific and practical conference "Quality - strategy of the XXI century" (Tomsk, 2001), Russian scientific conference with the participation of the CIS countries “Current problems of experimental and clinical morphology” (Tomsk, 2002), a city scientific and practical conference dedicated to the 40th anniversary of the Central Scientific Research Laboratory of Siberian State Medical University “Modern aspects of biology and medicine” (Tomsk, 2003), the Russian conference “Current Issues of urogynecology" (Tomsk, 2003), meetings of regional scientific and practical societies of obstetricians-gynecologists and morphologists (Tomsk, 2003-2004).
Scope and structure of the dissertation. The dissertation is presented on 204 pages and consists of an introduction, literature review, own observations, discussion, conclusions and practical recommendations. The bibliographic index contains 422 sources, of which 250 are in Russian and 172 in foreign languages. The dissertation contains 16 tables, 4 photographs, 32 microphotographs, 10 electron diffraction patterns, 5 graphs.
Modern view on the problem of chronic inflammatory diseases of the uterine appendages
In most countries of the world, in the last decade there has been an increase in the frequency of inflammatory diseases. gynecological diseases. Thus, in the United States, about 1 million women are registered annually with acute inflammation uterine appendages, in every fifth of them (15-20%) purulent-septic complications are detected, requiring surgical correction, transition to a chronic course inflammatory process noted in 45-70% [Hatcher R.F. et al., 1994; Savelyeva G.M. et al., 1997; Ms Neeley S.G. et al, 1998; Paternoster D.M. et al., 1998; Marks C. et al., 2002]. The age range of inflammatory diseases of the uterine appendages is very wide: young women - 14-17 years old - 4-15%; 18-35 years old 44-75%; over 36 years old - 10-22% [Smetnik V.P., Tumilovich L.G., 1998, 2003; Kolgushkina T.N. et al., 1998, Paavonen J., 1998; Westrom L., 1992; Ostensen et al., 2000]. For the dynamics of general morbidity various groups population during the reforms taking place in Russia in the last decade of the 20th century were characterized by unfavorable trends. Despite the fact that the overall incidence for 1991-1999 as a whole increased by only 10.5%, the proportion of diseases with a chronic and recurrent course has increased significantly. Frequency of inflammatory diseases of the pelvic organs for 1994-2001. increased in girls by 5.4 times, in women - by 1.3 times [Kulakov V.I. et al., 2001]. Inflammatory diseases of the female genital organs are characterized by a frequent transition to a chronic relapsing course with the formation of pelvic pain syndrome; reproductive, menstrual and sexual functions; lead to long-term disability [Bodyazhina V.I., 1978, 1981; Savelyeva G.M. et al., 1997; Ailamazyan E.K., Ustinkina T.I., 1991; Dergacheva T.I., 1996; Strizhakov A.N., Podzolkova N.M.. 1996; Tsvelev Yu.V., Kira E.F., 1996, 1998; Krasnopolsky V.I. et al., 1998; Savitsky G.A. et al., 2000; Kulakov V.I. et al. 2001; Westrom L., 1991; Brookoff D., 1994; Kottmann L.M., 1995; Gardo S., 1998; Watrelot A. et al., 1999].
Risk factors for the formation of CIDP are social disadaptation, changes in sexual motivation, high infection index, use of intrauterine contraception, intrauterine interventions (primarily abortion), untimely and inadequate treatment of acute inflammatory diseases of the pelvic organs [Savelyeva G.M., Sichinava L.G. , 1997; Samorodinova L.A. et al., 1998; Varela R. et al., 1995; Gareen I.F. et al., 2000; Grimes DA., 2000; Williams J.K., 2000; Champion J.D. et al, 2001; Crowley T. et al., 2001].
With inflammation of the pelvic organs of women, the pathological process in the uterine appendages in 60-78% of cases, according to International classification diseases (tenth revision) and Industry standards for the scope of examination and treatment in obstetrics, gynecology and neonatology (1999), corresponds to the diagnosis of “salpingitis” or “salpingoophoritis”. In the English-language literature, the term is used - "pelvic inflammatory disease" - "pelvic inflammatory disease", which means " clinical syndrome associated with microbial infection." This definition emphasizes the ascending nature of the process associated with infection, inflammatory in nature developing changes [Kate L.G. et al., 1988; Kulakov V.I. et al., 1998; Soper D.E., 1995].
The literature of recent years provides numerous data on changes in the clinical course and etiological structure of inflammatory diseases of the uterine appendages. Currently there is a tendency towards predominance indolent diseases with a protracted, asymptomatic course [Bodyazhina V.I. et al., 1990; Dyachuk A.V.1992; Savelyeva G.M., Antonova L.V., 1992; Akker L.V., Deryavkina R.S., 1998; Evseev A.A., 1998; Kira E.F., Tsvelev Yu.V., 1998; Krasnopolsky V.I. et al, 1999; Cates WJr. et al., 1996; Kottmann L.M., 1995; Broadnax J. 1993; 1997; Yanky E. et al., 1999].
Thanks to the development of new endoscopic and puncture methods for sampling directly from the site of inflammation, improvement of basic cultivation technologies, by the 90s of the last century, most researchers came to the consensus that the main causative agents of inflammatory diseases of the uterine appendages are associations of non-clostridial anaerobic microorganisms, gram-negative and gram-positive microbial flora [Ermoshenko L.V., 1992; Aksenenko K.B., 1995; Tsvelev Yu.V. et al., 1998; Faro S. et al, 1993; Jossens M.O.R. et al., 1993; Super D.E. et al., 1994; Szumala-Kakol A. et al., 2000; Baveja G. et al., 2001; Tsanadis G. et al., 2002]. Common components The structure of the causative agents of CIPV also includes sexually transmitted infections (STI), and, above all, gonococci, trichomonas, chlamydia, mycoplasma, ureaplasma and viruses [Aksenenko V.A. et al., 1996; Goldstein F.W. et al., 1994; Mandegor M. et al., 1995; Paavonen J. et al., 1996; Mc Gee Z.A., et al., 1999; Aral S.O., 2001]. The association of opportunistic pathogens deprives the disease of nosological specificity. Due to these features, etiological diagnosis is a dynamic process, including assessment of clinical signs of the disease, classical microbiological research and other methods (immunodiagnostics, PCR, gas-liquid chromatography, etc.) [Tsvelev Yu.V. et al., 1996; Dan M. et al., 1993; Eschenbach D.A. et al, 1997; Hefler L. et al, 1998; Rachinsky I. et al, 2000].
The importance of peloid therapy in the treatment of chronic inflammatory diseases of the uterine appendages
Studying the chemical composition, sanitary and biological condition, biological action Many works are devoted to therapeutic mud [Cherepanova M.N., Kotova T.I., 1981; Bogolyubov D.N., Ulashchik B.C., 1985; Leshchinsky A.F., Zuza Z.I., 1985; Tsarfis P.G., Kiselev V.B., 1990; Shustov L.P., 1996, etc.].
The medicinal effects of mud are caused by a combination of mechanical, thermal, biological and chemical effects, but the specificity of medicinal mud is determined mainly by their physicochemical characteristics. They are determined by gas and mineral composition, pH of the environment, the presence of various microelements, as well as organic substances that enter into certain relationships with cellular elements skin, exteroceptors, sweat and sebaceous glands[Nizkodubova SV. et al., 1981; Mikheeva L.S., 1984; Gorchakova G.A., 1986]. Under the influence of these processes, both local and general reactions of various functional systems of the body arise. Mineralization and chemical composition natural factors determine the specificity of the body's responses that occur against the background of their nonspecific influence [Zolotoreva T.A., 1988; Karpovich O.A., 1989; Balak K., 1969; Zrubek N., 1974]. According to I.E. Oransky, P.G. Tsarfis (1989) specificity for the effect of the physical therapy factor most likely manifests itself on tissue, cellular, subcellular and molecular levels primary physicochemical changes. For more high level this specificity of action is obscured by the involvement of general response systems in the body’s response - endocrine glands, pituitary-adrenal and nervous systems. The implementation of the therapeutic effect of peloids is carried out by increasing the synthesis of one’s own hormones, neurotransmitters, biologically active substances, influence on immunomorphological and enzyme-chemical processes, with the help of which impaired body functions are regulated and restored [Gorchakova G.A., 1986; Tsarfis P.G., 1989].
The results of clinical, biochemical and morphological studies indicate that the use medical complexes, including sulfide mud with a temperature of 44 C, has negative impact on the central myogenic and metabolic regulation of blood circulation, which affects an increase in vascular tone, a decrease in blood supply and leads to a deterioration in tissue trophism [Oransky I.E., Tsarfis P.G., 1989]. Clinically, this was expressed in excessive activity of the inflammatory process and an increase in its exudative component. Many researchers explain the negative role of the temperature factor in peloid therapy for inflammatory diseases by the increased release of histamine and a decrease in its inactivation [Yasnogorodsky V.G., 1984; Leshchinsky A.F.. Zuza Z.I., 1985]. Mitigated, gentle methods of peloidotherapy, excluding temperature and mechanical components of stimuli, contribute to improvement peripheral circulation, a decrease in the level of hexoses and seromucoid in the blood serum, hydroxyproline in daily urine, which together indicates a decrease in dystrophy and an increase in the regeneration of cellular structures in altered tissues [Tsarfis P.G., 1989]. In gynecological practice, therapeutic mud is mainly used for inflammatory diseases and, as a rule, native mud is used in the chronic stage of the process. In addition, traditional mud therapy is carried out with conditioned material and, mainly, in the conditions of functioning resorts. Important scientific problem the use of natural factors is to create mud preparations that would be as effective as native mud due to the preserved chemical composition, and in order to optimize treatment could be prescribed in combination with various preformed physical factors [Ryzhova G.L., Khasanov V.V. , 1995; Samutin N.M., Krivobokov N.G., 1997; BaierH., 1976; Goecke S, 1986].
The first attempts to create such mud preparations and use them in non-resort conditions were made in Germany in the second half of the 19th century, and somewhat later in Russia. But the most intensive development of methods for obtaining new mud preparations, studying their chemical composition, experimental and clinical assessment of their effectiveness medicinal use began only a hundred years later, in the second half of the 20th century [Lesnoy S.K., 1950]
The created filtrates, water-mud extracts, steam distillates, mud solutions began to be successfully used in ophthalmology, neurology, arthrology, pulmonology, gastroenterology and gynecology [Bogolyubov V.M., 1985; Trapeznikova N.K., Orlova L.P., 1988; Shustov L.P., 1996; Dzhabarova N.K. et al., 1997].
Later there was scientific search and the development of methods for the production of mud preparations that allow preserving the chemical composition of native mud and the creation of dry preparations that are cost-effective, have a long shelf life and allow them to be used in different dosages depending on the severity pathological process[Altunina L.K. et al., 1987; Agapov A.I. et al., 1999]. Since 1980, development has been carried out in Tomsk complex problem“Mud preparations” and new methods for obtaining silt mud extracts and dry preparations based on extracts and brine have been created. Chemical analysis of solutions of dry preparations showed their qualitative similarity with liquid extracts[Ryzhova G.L. et al., 1983. 1985; Bogdanova I.V., Lyutova O.V., 1983; Matasova S.A., Ryzhova G.L., 1988], and experimental studies revealed their high biological activity [Matis E.Ya. et al., 1984; Vengerovsky A.I. et al., 1984; Saratikov A.S. et al., 1986, 2001; Vorobyova T.G., 1988; Nechai G.M., 1988; Shustov L.P., 1988; Tikhonovskaya O.A., Logvinov S.V. et al., 1987, 1998, 1999, 2000; Vengerovsky A.I., 2002; Petrova M.S., 2002].
The creation of mud preparations containing the entire complex of biologically active substances contained in native mud makes it possible to expand the indications for peloid therapy for CIPM and use it in combination rehabilitation measures in the early stages after laparoscopic treatment for chronic inflammation of the uterine appendages. Treatment procedures using mud preparations exclude thermal and mechanical factors impact, significantly reduce the load on cardiovascular system. The clinical effectiveness of peloid therapy is increased by combination with preformed physical factors: low voltage direct current (peloelectrophoresis), ultrasound (pelophonophoresis), magnetic field (peloinductothermy) and others [Malysheva SM., 1965; Morozova N.N., 1973; Seitenov E.S. et al., 1988; Mishchuk A.V., Gorelyuk I.P., 1989; Shafikova G.V., 1989; Matis E.Ya. et al., 1996; Petrova M.S., 1999; Tikhonovskaya O.A., 2000].
Morphology of the oviducts and ovaries of white rats during chronic inflammation caused by the introduction of a culture of Staphylococcus aureus
When opening the abdominal cavity of animals removed on the 30th day from the experiment with monocultural inflammation in combination with deserosis of the visceral peritoneum of the oviducts and scarification of the integumentary epithelium of the ovaries, the adhesive process is moderately pronounced, but widespread. Multiple thin, avascular, transparent and translucent adhesions are identified, which are removed with slight tension on the mesosalpinx or mesoovary (Fig. 1). The uterine horns are somewhat swollen, hyperemic, and sometimes present in the distal parts, with the involvement of the oviducts, hydrosalpinx-type changes. When opening the latter it is revealed clear liquid in a volume of up to 0.5-1.0 ml. A small amount of free exudative fluid is noted in the abdominal cavity. The parietal and visceral peritoneum is moderately hyperemic.
Histological examination of the ovaries and oviducts reveals a picture of a chronic inflammatory process with a significant proliferative component. Numerous adhesions of the ovaries, oviducts with the omentum and the formation of fibrous tissue are revealed. In the described areas, infiltrates containing cells of the macrophage series are found (Fig. 2), as well as oxyphilic masses in the area of adhesions and a violation of the integrity of the integumentary epithelium of the ovaries.
By the 30th day of the experiment, hemodynamic disturbances were detected in the cortex and medulla of the ovaries and the wall of the oviducts. Vessels venous type in the medulla of the ovary are moderately plethoric. In some of them, phenomena of prestasis and stasis of blood cells, marginal location of leukocytes, migration of the latter through the vascular wall are noted, and in some - phenomena of thrombosis, edema of the intercellular substance (Fig. 3). Sometimes hemorrhages are detected in the medulla and cortex of the ovary. Along the course of individual blood vessels of the ovarian medulla and in the wall of the oviducts, the phenomena of perivascular sclerosis are determined. These disorders are accompanied by karyopyknosis and necrobiosis of interstitial cells (Fig. 4).
Focal proliferation of fibrous loose connective tissue noted between the generative elements of the ovarian cortex. In the medulla of the ovaries, phenomena of fibrosis, proliferation of connective tissue cells, and the formation of cellular infiltrates are detected. When stained by Brachet, lymphoplasmacytic infiltrates are detected in the medulla of the ovaries and the wall of the oviducts (Fig. 5), as well as accumulations of tissue basophils with symptoms of partial degranulation.
Some primordial, secondary and tertiary follicles are susceptible degenerative changes, which are manifested by the destruction and cytolysis of oocytes, homogenization of the cytoplasm of the latter. In some primordial and growing follicles, oocyte nuclei are not detected, and their cytoplasm is either sharply vacuolated or subject to destruction. In some follicles, along with these changes, the follicular epithelium is discomplexed, susceptible to necrobiotic and necrotic changes, and the eviction of macrophages into the cavity of such follicles was noted (Fig. 6). Sometimes in secondary and tertiary follicles the initiation of meiosis and pseudofragmentation of oocytes is determined, blastomeres with micronuclei are detected (Fig. 7).
With electron microscopy, some follicular epithelial cells are susceptible to rough destructive changes. The nuclei in them are pyknotic, with an unevenly high electron density of karyoplasm and homogenized chromatin, and contain cavities of unequal size. The nuclear envelope is mostly destroyed, and the contents of the nucleus disintegrate.
Morphology of oviducts and ovaries of white rats with chronic aseptic inflammation
When opening the abdominal cavity of animals removed on the 30th day from the experiment with deserosis of the visceral peritoneum in combination with spraying microdoses of talc, the adhesive process is pronounced and widespread. Multiple thin, translucent and opaque adhesions are identified, which are removed with significant tension on the mesosalpinx or mesoovary. The uterine horns, as in the experiment with the introduction of a culture of Staphylococcus aureus, are somewhat swollen, hyperemic, and in some cases intimately fused with the ovaries, mesosalpinx, omentum and fatty pendants of the intestines. A small amount of free exudative fluid is noted in the abdominal cavity. The parietal and visceral peritoneum are moderately hyperemic.
Histological examination of the ovaries and oviducts reveals a picture of a chronic inflammatory process with a pronounced proliferative component. Numerous adhesions of the ovaries, oviducts with the omentum and the formation of fibrous tissue are revealed (Fig. 29). In these areas, infiltrates containing macrophage cells, numerous inclusions of talc crystals, as well as giant cells are found foreign bodies(Fig. 30).
By the 30th day of the experiment, as in the model with monocultural inflammation, hemodynamic disturbances are detected in the cortex and medulla of the ovaries, the wall of the oviducts, manifested by prestasis and stasis of blood cells, marginal arrangement of leukocytes, migration of the latter through the vascular wall, and sometimes by the phenomenon thrombosis and edema of the intercellular substance.
In the cortex of the ovaries and the wall of the oviducts, giant cells of foreign bodies are often found near talc crystals. The described cells have an elongated shape, as well as several nuclei. In the medulla of the ovaries, fibrosis and proliferation of connective tissue cells are detected. Moderately pronounced phenomena of fibrosis are observed in the lamina propria of the oviduct mucosa.
A significant part of primordial, secondary and tertiary follicles are susceptible to atresia. Atretic follicles and bodies with a homogenized, thickened PAS-positive zona pellucida are detected (Fig. 31). The oocytes of such follicles have low glycogen content and cytoplasmic edema, and the follicular epithelium is discomplexed and subject to necrobiotic and necrotic changes (Fig. 32).
On the 40th day of the experiment in the abdominal cavity, the adhesive process becomes even more pronounced. Adhesions of various shapes, with small visualized vessels, are removed with damage, fate
A giant cell of a foreign body and talc microcrystals in the area of adhesions between the omentum and the ovary on the 30th day of experimental aseptic inflammation. Hematoxylin and eosin staining. Uv. 600. animals, mesosalpinx and mesoovary. In some cases, hydrosalpinxes with serous-hemorrhagic contents occur.
Histological examination shows proliferation and pronounced sclerotic changes in the connective tissue in the cortex and medulla of the ovaries and in the wall of the oviducts. In the adventitia of blood vessels, there is a proliferation and homogenization of collagen fibers, which have intense fuchsinophilia when stained according to Van Gieson and exhibit a high affinity for leukofuchsin when performing the CHIC reaction.
On the part of the generative apparatus of the ovaries, the phenomena of atresia and reduced content of the corpus luteum still persist. Destruction, karyolysis of oocytes, homogenization of the cytoplasm of the latter, metaplasia and discomplexation of the follicular epithelium are detected. Between the generative elements in the cortical layer of the ovaries, directly under the covering epithelium, foreign body cells, as well as talc crystals, are often detected.
Similar to the previous period of the experiment, hemodynamic disorders are detected in the form of microcirculation disorders, single hemorrhages in the cortex and medulla of the ovary, and the wall of the oviducts.
Dystrophic processes are also detected in the mucous membrane of the oviducts. Thus, in a number of cases, uneven height of epithelial cells and a low content of PAS-positive substance on the apical surface of the latter are detected.
On the 60th day of the autopsy experiment, the adhesive process is even more pronounced. Dense adhesions with visualized vessels intimately surround the ovaries and oviducts, involving intestinal loops and the omentum in the process (Fig. 33). Changes in the distal parts of the uterine horns and oviducts in the form of hydrosalpinxes are noted in two-thirds of the observations.
