Method of assessment the course and prognosis of purulent wounds at phlegmon of the maxillofacial area

 

(57) Abstract:

The invention relates to medicine, in particular to dentistry. The method allows to increase the efficiency evaluation of the course and prognosis of the development of purulent wounds with phlegmon of the maxillofacial area. Conduct a visual assessment of the amount and nature of the exudate, diagnostic cytochemical methods of research of neutrophils in the wound, including the determination of the activity of chromatin DNA and the activity of myeloperoxidase, one can also define the integral functional activity of neutrophilic granulocytes by further study of the content of cationic proteins and glycogen, and then determine the total biological activity indicator - tissue index of neutrophil granulocytes (TING) wound exudate by the formula: RATING=(DNA:(MP+KB+CH))1000, expressed in arbitrary units, where DNA activity of chromatin core; MP - myeloperoxidase activity; KB is the content of cationic proteins; GL - content of glycogen; 1000 is the conversion factor thousandths in whole numbers and with increasing magnitude TING on the 3rd day of treatment relative to its defined value, bar the us, and at lower values TING below 100% predict a prolonged healing process, with the risk of complications.

The problem of treatment of phlegmon of the maxillofacial area (FCLO) is still relevant [N. N. Bazhanov, V. A. Kozlov and others, 1996]. The end result of a balanced and coordinated work of all regulatory systems homeostasis in patients after opening FCLO is the relief of the inflammatory process in the festering wound and its optimal regeneration. The most important cellular element of the first phase currents of the wound healing process are neutrophilic granulocytes (NG). They were the first among other cells appear in the place of acute inflammation and exercise in the wound “killing” bacteria, phagocytosis, and also participate in regulation of non-specific antimicrobial defense of the organism [M. M. Dale, J. To.Shaped, 1998]. The effectiveness of their actions is the creation of an optimal level of alternative reactions in the wound to cleanse and balanced development of further proliferation. Criteria activity NG can be elected cytochemical indices of the nucleus and cytoplasm of these cells [M. I. Kuzin, B. M. Kostyuchenok, 1990]. However, information about cytochemical study NG the hospitals directly in the wound in the available literature is extremely small, largely restricted to expensive equipment electron microscopic autoradiography and mainly devoted to the research of purulent wounds with phlegmon other localizations.

There is a method of assessing the flow of purulent wounds [C. E. Pisarevsky, 1981], based on cytochemical detection of the blood smears and drugs-the fingerprints from the surface of inflammatory foci lysosomal cationic proteins with cytochemical determination of average coefficient (CCS) according to the formula

The CCS=(3A+2B+1.5+1+0.5 d+e)/100,

where letters (a-e) - number of identical colored cells with a certain degree of okrashivaemoy cytoplasm solid green. Figures (3-0) - the degree of intensity of okrashivaemoy.

The reduction of the CCS cationic proteins reflects the inhibition of the bactericidal functions of polymorphonuclear leukocytes (PMNL). Increasing the CCS is the criterion of stabilization.

So for example, if FCLO [N. N. Bazhanov and others, 1992] VFM cationic proteins of polymorphonuclear leukocytes in the peripheral blood is moderately - 1.232 metric (1,58). Under favorable for the application of the secondary seams he grows up to 1,328. In inflammation of the CCS polymorphonuclear leukocytes increases with 0,861 to 0,980.

Under atrophying of granulocytes kislorodozawisimae microbicides, but rather the level of cationic proteins, and does not take into account the importance and activity of other important factors antimicrobial protection NG.

2) Use for carrying out the methods of the alcohol solution of fast green FCF limits its wide application due to its high cost

Despite these disadvantages of the discussed method is widely used for clinical and laboratory definitions cytochemical indicators PMNL.

The closest analogue adopted for the prototype, is a method of predicting the course of the wound process (Patent for invention №2146367, Gumenyuk S. E., and others), providing for the study of patients with purulent-inflammatory diseases of the soft tissues of the peripheral blood, with the simultaneous study of blood taken from the wound. This establishes a correlation relationship between these indicators and the detection of inverse correlations predict torpid or complicated the course of the wound process, and with direct correlations - uncomplicated wound healing process.

The disadvantages of the prototype of the Ana is the functional activity of leukocytes tissue pool, which can vary significantly depending on the combination of local conditions. However, the principle of the proposed method is compared cytochemical indices of peripheral blood leukocytes and wound, when it is not possible to identify specific quantitative cytochemical leukocytes wound exudate associated adverse for local wound healing process, and hence the possibility of developing septic complications.

2) On the merits of the proposed method study should be carried out twice (peripheral blood and wound exudates), and therefore dmocrate increase the time and economic costs, indirect technical artifacts. Methodological necessity of additional infestations severe patients also obviously not an advantage.

3) Microbicide activity of leukocytes was studied by assessing the activity of myeloperoxidase and NBT-test, which are markers oxygendependent systems. However billingovaya function of leukocytes includes and other important necesariamente microbicide system that was not reflected in predannogo study of energy resource cell glycogen, the necessary substrate for the implementation of biosynthetic functions.

5) One of the indicators of the functional activity of leukocytes in the comparison method is the property of anisotropy kernel, based on the known principle that heterochromatinization kernel implies the increase of the functional activity of the cells, and achromatization its reduction. However, the study is built on the visual dimension densitometric density, which significantly reduces the quantitative information of the method or implies the presence of a very expensive computerized equipment and maintenance of its personnel.

The objective of the invention is to increase the efficiency evaluation of the course and prognosis of the development of purulent wounds with phlegmon of the maxillofacial area.

The essence of the invention is the determination of the integral functional activity of polymorphonuclear granulomatous wound exudate through further study of the content of cationic proteins and glycogen, and then determine the total biological activity indicator - tissue index of neutrophil granulocytes (TING) wound exudate by the formula

TING=(DNA:(MP+KB+CH))

The method is as follows.

Fence cytological material is carried out according to the method of M. P. intercession and M. S. Makarova (1942). Prints of wound exudate put on fat-free glass slides and fixed with acetonitrile (ratio 1:1) and pairs of 40% formalin for 15 and 5 minutes, respectively. Smears, fixed acetonitrile mixture is subjected to hydrolysis in 5 N HCL at 37C for 8 minutes [Erenpreisa E. A., 1990], and then paint in standardized conditions with Schiff's reagent for Felgen DNA. Painted thus prints, after washing in two changes of sulphurous water and drying, is subjected to absorption photometry on the installation FAML-1a method two areas by Garcia (1969) at a wavelength of 5308,2 on MT. Subice (1967). Myeloperoxidase (MP) identified by the method of Sato and Selkia (1928), and glycogen (GL) - Mac Manusu modification A. Pearce (1961). Analysis was performed by semiquantitative method Astaldi and Verga (1957).

At the opening of FCLO cytochemical indices of the nucleus and cytoplasm NG wound exudate defined by the proposed method are in the services. units: DNA - 0,81±0,01; KB - 1,740,06; MP - 0,95±0,08; CH - 1,51±0,12. The estimated value of the TING equal - 192,8612.7 services. units In patients with favorable type of the inflammatory process cytochemical indices NG wound exudate was on 3 day: DNA - 0,960,002; KB - 0,870,03; MP - 0,630,04; CH - 1,430,07; TING - 327,64 srvc. units At the time of imposition of secondary sutures - DNA - 0,870,001; KB is 1.960,04; MP - 1,640,06; CH - 1,990.05; TING - 155,63 srvc. units In patients with unfavorable type of the inflammatory process (required re-revision of gnment overlay secondary sutures exceeded 8 days and so on) identified the following cytochemical indices of the nucleus and cytoplasm NG wound exudate:

3 day: DNA - 0,670,002; KB - 2,110,04; MP -1,420,05; GL - 2.00.07; TING - 121,16 UEL. unit

at the time of imposition of secondary sutures - DNA - 0,480,001; KB - 2,980,04; MP - 1,910,06; CH - 2,820.05; TING - 62,25 srvc. u..

The technical result of the invention is:

- TING allows to obtain the exact objective presented on the implementation of the overall biological activity NG wound exudate based on an integrated and holistic use of fixed cytochemical indices of the nucleus and cytoplasm NG;

- used cytochemical indicators adequately reflect the main (oxygendependent and kislorodozawisimae) microbicide function NG implemented on the basis of glycoengineering substrate under the General determenirovana synthetic activity of the nucleus;

- the application of the proposed cytochemical indicators, including the determination of the degree of dissociation between the nucleic acid is a broad use;

Theoretical background of the proposed method was the rule Hertwig providing that only at a certain eternallifeseries.com the ratio of the cell is in equilibrium (CIT. by E. robertis set up, V. Novinski, F. the nuclear station, 1973) or expressed in the formula VN/Vk-VN=const (CIT. by F. ster, Century, Mellendorf, 1936), where VN is the volume of the nucleus, VC is the cell volume, changing the biological activity of this ratio is changed. However, due to the fact that the rule was removed for histological studies, the area calculation conformationally complex kernel NG is known difficulties, and that the geometric area ratio of the nucleus and cytoplasm only indirectly reflects the functional activity of the cells, to use it for the integral biosynthetic activity NG of wound exudate is not possible. In this regard, only a one-stage study of cytochemical indicators of complex functional activity of NG can provide the most comprehensive assessment of the latter.

The method is tested on 74 patients with phlegmon of the maxillofacial area. In the analysis of the case histories of the patients were divided into 2 groups, including: 1 gr. - patients requiring secondary seams n the day.

Example 1

Patient L., 42 years old (case History No. 2340) received purulent Department of maxillofacial hospital regional clinical dental clinic (IAC) in the 135518.09. 2002 with a diagnosis of odontogenic phlegmon kralovice-jaw, okolopochechnogo spaces and maxillo-speaking groove to the right and under the mask anesthesia external access of the submandibular region uncovered interested fiber space obtained purulent contents. Conducted necrectomy, antiseptic treatment of wounds taken brushstrokes-prints. DNA - 0,85; KB - 1,73; MP - 0,96; CH - 1,53. TING=((0,85/(1,73+0,96+1,53))1000=201,4 srvc. unit

On the next day and the next day the patient's condition is satisfactory. On the 3rd day in a wound is a minor serosanguineous discharge. While bandaging after an active antiseptic treatment of wounds taken brushstrokes-prints. DNA - 0,94; KB - 0,88; MP - 0,64; CH - 1,45; TING - 316,50 srvc. unit

On the 6th day of inpatient treatment (24.09.02) sick new no complaints. The General condition is satisfactory. In the wound are defined juicy fresh granulation. After antiseptic treatment of wounds taken brushstrokes-prints, under IU secondary sutures. DNA - 0,88; KB - 1,97; MP - 1,63; CH - 1,89; TING - 160,29 srvc. unit

On the following day the patient is new no complaints. The General condition is satisfactory. The skin around the wound and the regular color, painless on palpation. Drainage saved. Seams wealthy. Antiseptic treatment of wounds. The washing water is clean. Removed the glove drainage imposed aseptic bandage.

01.10.02, in connection with a satisfactory General and local condition of the patient's full recovery was discharged from the hospital.

Thus, the detected magnitude of TING on the 3rd day of treatment with FCLO to 157% against the values defined at the opening of FCLO, hypothetically indicates favorable type of flow of a purulent process. Indeed, postoperative period proceeded satisfactorily. On the 6th day of inpatient treatment were superimposed secondary seams. Total hospital stay was 13 days.

Example 2

Patient 3. (History No. 845) received purulent Department of maxillofacial hospital regional clinical dental clinic (IAC) at 094012.04.2003, with a diagnosis of odontogenic phlegmon kralovice-jaw, okolopochechnogo area uncovered interested fiber space, received serous-purulent contents. Conducted necrectomy, antiseptic treatment of wounds taken brushstrokes-prints. DNA - 0,84; KB - 1,75; MP - 0,97; CH - 1.55V. TING=((0,84/(1,75+0,97+1,55))1000=196,72 srvc. unit

In the opened kletchatii spaces left hard drainages. The wound superimposed aseptic bandage. Assigned to anti-inflammatory, antibacterial and desensibiliziruyuschee therapy.

13.04.03 and 14.04.03 the patient's General condition was satisfactory, the local status is not changed, was conducted antiseptic treatment of wounds and General anti-inflammatory treatment.

15.04.03 the patient began to Lodge complaints for swelling in the temporal region that appeared the night before. Have any limitation of mouth opening, and appeared soreness when swallowing on the right. The General state of moderate severity. On physical examination, is determined by the spread of purulent process in the adjacent cellular tissue space. Infiltrate the temporal region, the skin in the crease not going, painful on palpation. Palpation over the tuberosity of the maxilla and laterally from the front edge of the branches of the lower jaw sharply bresnen the wounded and function. Diagnosis: cellulitis temporal region, apex n pterygopalatine fossae, kralovice-jaw, okolopochechnogo, palmaseravillage spaces to the right.

15.04.03 under General anesthesia an autopsy and revision interested cellular tissue areas. Received purulent contents. Conducted necrectomy and abundant antiseptic treatment of wounds sodium hypochlorite taken brushstrokes-prints.

DNA - 0,83; KB - 1,99; MP - 1,67; CH - 1,87; TING - 150,09 UEL. unit

In the opened fiber spaces left hard drainages. The wound superimposed aseptic bandage impregnated with sodium hypochlorite. Assigned to anti-inflammatory, antibacterial and desensibiliziruyuschee therapy. The patient was transferred to the intensive care unit.

16.04.03 sick new no complaints. The General state of moderate severity. Stable hemodynamics. Physiological functions and appetite are normal. The patient actively moves independently within the chamber and compartment. Locally: bandage impregnated purulent hemorrhagic discharge. Collateral edema temporal, parotid-masticatory area adequate postoperative intervention. The drains are functioning. In the wash water is yourself at any time. Data for the distribution of purulent process is not revealed. The wound is treated with sodium hypochlorite and imposed aseptic bandage impregnated with sodium hypochlorite. The patient remains in the ICU. Receives treatment according to individual worksheet assignments.

17.04.03 - 18.04.03 sick new no complaints. The General condition is satisfactory. From the wound serous-purulent discharge.

The drains are functioning. Held twice daily treatment with sodium hypochlorite. 18.04.03 swabs taken fingerprints from the wound. DNA - 0,88; KB - 1,67; MP - 0,98; CH - 1,52. TING=211,03 srvc. unit

In the next day to find the patient in the hospital, General condition improved markedly. The patient was transferred from the emergency Department in contaminated surgery. Wounds were daily treated with a solution of sodium hypochlorite. Stopped explicit exudative processes, there were young fresh granulation, which allowed 25.04.03 to impose secondary seams and were taken brushstrokes-prints.

At the time of imposition of secondary sutures - DNA - 0,670,002; KB - 2,110,04; MP - 1,42±0,05; CH - 2,0±0,07; TING - 121,16 srvc. unit

26.04.03 new patient complaints not prizhiznennyh palpation. Soft drainages saved. Seams wealthy. Antiseptic treatment of wounds. The washing water is clean. Removed the glove drains imposed aseptic bandage.

30.04.03, in connection with a satisfactory General and local condition, the patient's full recovery was discharged from the hospital.

Dynamics of values TING in this patient enough informative, represents a diagnostic and prognostic interest. The decrease in the value TING to 76% against the values defined at the opening of FCLO, correlates with the deterioration of the General condition of the patient, the spread of purulent process in the adjacent cellular tissue space. Adequate dissection and re-revision interested cellular tissue areas, active use of sodium hypochlorite, which has strong antiseptic and immunocorrective action, completely suppresses the inflammatory process that is inextricably linked with the restoration of the functional usefulness NG of wound exudate.

Use TING for research NG wound exudate purulent wounds in FCLO does not represent a technical and economic difficulties will not vichet the use of expensive laboratoriet sampling of material from the patient manages approximately 2 hours. However, its use allows precision to assess the overall biosynthetic activity NG wound stage of purulent wounds in patients with phlegmon of CHLO, to predict the course of purulent wounds and, consequently, the length of hospitalization of the patient.

Literature

1. Bugayov N. N., Kozlov C. A., Maximov Y. M. Status and prospects for the prevention and treatment of purulent inflammatory diseases of maxillofacial area //Dentistry: Spec. Release. - 1996. - S. 38.

2. Dale M M, J Shaped. K. Guidance for immunopharmacology. - M.: Medicine. 1998. - S. 32-48.

3. Kuzin, M. I., Kostyuchenok B. M. Wounds and wound infection. - A guide for physicians. M., 1990. - 591 S.

4. Pisarevsky C. E., Masing Y. A. //Lab. Case. - 1981. No. 10. - N-579-582.

5. Bazhanov N. N., Usmanov, R. F., Horn, K. A. Use of hyperbaric oxygenate and galileomobile laser radiation to the treatment of patients with odontogenic a phlegmon of the face and neck //Dentistry. - 1992. No. 2. - S. 38-40.

6. Gumenyuk S. E., Iglewski A. A., Potemin S. N., Galenko-Yaroshevsky P. A., Usmanov D. And S. Pavlenko, a Method for predicting the course of the wound process //the Patent for invention №2146367.

7. Pokrovskaya M. P., Makarov M. S. Cytology ORGANIZACIJA chromatin in the nucleus of interphase cells //Riga, 1990.- 1-114 C.

9. Garcia, A. and IIS R. Odnovolova method of two squares, is used to cytophotometry smears and prints fabrics //In the book: Introduction to quantitative cytochemistry. - M.: MIR. - 1969. - S. 196-201.

10. Cubic M, Color cationic protein bromophenol blue // lab. case. - 1967. - N9. - S. 67.

11. Sato, J. S. et Selkia L. //S. J. Clin. Med. 1928. - V. 13.- P. 1058.

12. Pearse, A. G. E. - Histochemistry, theoretical and applied, Ed. II-a, Ed. Little. Brown, Boston, 1961.

13. Astaldi G. L. Verga //Acta haematol. (Basel). - 1957.- Vol. 173. - P. 129.

14. Robertis set up E., Novinsky Century, the nuclear station F. the Biology of cells, M, - 1973. - S. 34.

15. Star F., Mellendorf Century Textbook of histology. M. - L., 1936. - S. 66.

Method of assessment the course and prognosis of purulent wounds at phlegmon of the maxillofacial region, including a visual assessment of the amount and nature of the exudate, diagnostic cytochemical methods of research of neutrophils in the wound, including the determination of the activity of chromatin DNA and the activity of myeloperoxidase, wherein define the integral functional activity of neutrophilic granulocytes by further study of the content of cationic proteins and glycogen, and then determine the total biological indicator G SRC="http://www.fips.ru/chr/183.gif" ALIGN="ABSMIDDLE">1000, expressed in arbitrary units, where DNA activity of chromatin core; MP - myeloperoxidase activity; KB is the content of cationic proteins; GL - content of glycogen; 1000 is the conversion factor thousandths in whole numbers and with increasing magnitude TING on the 3rd day of treatment relative to its value defined directly at the opening phlegmons in the maxillofacial region predicts favorable type of flow festering wounds, and at lower values TING below 100% predict a prolonged healing process, with the risk of complications.

 

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