Like other respiratory viruses, COVID-19 has extrapulmonary manifestations. The effect of the virus leads to the cardiovascular system (CVS) damage in particular, which pathophysiological mechanisms are not fully understood. In this article we analyze modern ideas about COVID-19, consider possible
links of pathogenesis, make an attempt to systematize pathophysiological mechanisms of cardiovascular impairment and its complications, analyze the relation with cardiovascular comorbidity, describe pathomorphological features and discuss possible long-term prognosis. The information in this article can contribute to understanding the two-way interaction of cardiovascular diseases and the effects of COVID-19 in order to develop effective preventive measures and make the right decision in choosing therapeutic tactics for a patient. 

 BACKGROUND The self-isolation regime introduced to limit the spread of COVID-19 disrupted the habitual way of life of the majority of the population, which could cause increased anxiety and depressive states in some citizens and lead to the development of acute exotoxicosis.

AIM OF STUDY To identify the impact of the COVID-19 pandemic on the structure of acute poisonings based on their comparative analysis for March-May in 2019 and 2020.

MATERIAl AND METHODS “Hospital patient cards” of patients who were treated in the Department of Acute Toxicosis and Somatopsychiatric  Disorders of the N. V. Sklifosovsky Research Institute for Emergency Medicine in March–May, 2019 and 2020. The Statistica 10.0 program was used for data processing. 

 RESUlTS The total number and gender composition of patients with acute poisonings (AP) did not differ significantly in the compared periods. In 2020, the share of people aged 30–39 increased by 23%, while patients over 50 decreased by 7%. In 2020, the frequency of AP caused by medicines decreased by 10%, with sedatives and antidepressants prevailing. There has been an increase in cases of overdose with NSAIDs, antibiotics and antiviral drugs, probably as a result of self-treatment for Covid-19.
The share of drug and psychoactive substance poisoning increased by 5%, mainly due to overdoses of synthetic drugs and combinations of drugs of different groups. At the same time, the number of cases of recreational drug use decreased 2.4-fold.
In March-May 2020, the number of patients with severe AP caused by alcohol increased 4-fold, and the number of people with other forms of AP hospitalized with alcohol intoxication grew 2.7-fold.
Additionally, twice as many household AP have been caused by chlorine vapor, as well as poisoning with isopropyl alcohol, which can be associated with frequent improper use of disinfectants.

CONClUSION Thus, the pandemic and the introduction of restrictive measures for COVID-19 affected the structure of acute exotoxicosis in Moscow in the period March-May 2020. The revealed changes in the structure of acute poisoning to a certain extent reflect global trends. 

 AIM OF STUDY Study of hospital results of emergency carotid endarterectomy (CEE) and carotid angioplasty with stenting (CAS) in the acute period of acute cerebrovascular accident (ACVA).

MATERIAL AND METHODS From January 2008 to August 2020, the study included 615 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), operated on in the acute period of ischemic stroke (within 3 days from the onset of stroke). Depending on the type of revascularization implemented, all patients were divided into 2 groups: group 1 — CAS (n=312); 2nd group — CEE (n=357). Inclusion criteria were as follows: 1. Mild neurological disorders: NIHSS score 3–8; Modified Rankin Scale score 2 of less; Barthel Scale > 61; 2. Indications for CEE / CAS  according to the current national recommendations; 3. Ischemic focus in the brain not more than 2.5 cm in diameter. Exclusion criteria: 1. Presence of  con-traindications to CEE / CAS. Carotid angioplasty with stenting was performed according to the standard technique; in all cases, distal embolism  protection systems were used. Carot-id endarterectomy was performed  according to the classical and eversion techniques. When the retrograde pressure in the ICA was less than 60% of the systemic pressure, a temporary shunt (TS) was installed. In the postoperative period, all patients underwent multispiral computed tomography (MSCT) of the brain. In the absence of negative dynam-ics in the neurological status, MSCT was performed on the 7th day after the operation, if available, it was performed urgently. The checkpoints were the development of such unfa-vorable cardiovascular events as death, myocardial infarction (MI), stroke / transient is-chemic attack (TIA), “mute” stroke, “mute” hemorrhagic transformations, combined
end-point (death + all strokes / TIA + MI). Strokes were mute if diagnosed according to MSCT, without symptoms.RESULTS In 69% of diabetic patients with anterior myocardial infarction and in 63% of patients with posterolateral MI 12 months after PCI, signs of LV inferiority were revealed in the form of an increase in the indices of end-diastolic and systolic volumes of the LV and low ejection fraction (≤45%). In patients without diabetes, these figures were 18% and 31%, respectively. High concentrations of NT-proBNP on the first day of myocardial infarction after PCI were of the greatest value in the  diagnosis and prognosis of LV UR after 12 months.

RESULTS When analyzing hospital complications, significant differences in the frequency of lethal outcome were not obtained (group 1: n=6 (1.92%); group 2: n=8 (2.24%); p=0.98; OR=0.85; 95% CI 0.29–2.49); MI (group 1: n=5 (1.6%); group 2: n=5 (1.4%); p=0.91; OR=1.14; 95% CI 0.32–3.99 ); ACVA (ischemic type) / TIA (group 1: n=5 (1.6%); group 2: n=6 (1.7%); p=0.82; OR=0.95; 95% CI 0.28–3.15), as well as “mute” ACVA (group 1: n=7 (2.2%);  group 2: n=15 (4.2%); p=0.23; OR=0.52; 95% CI 0.21–1.3). However, the vast majority of hemorrhagic transformations (group 1: n=2 (0.64%); group 2:  n=13 (3.6%); p=0.018; OR=0.17; 95% CI 0.03–0.76) and all “mute” hemorrhagic transformations (group 1: n=0; group 2: n=26 (7.3%); p=0.001;  OR=0.02; 95% CI 0.001–0.33) were observed only in the CEE group, which was reflected in the maximum values of the combined end point: group 1: n=22 (7.05%); group 2: n=73 (20.4%); p<0.0001; OR=0.29; 95% CI 0.17–0.48). Thus, in the CEE group, every 5th patient had a complication.

CONCLUSION Carotid angioplasty with stenting is the safest method of revascularization for patients in the acute period of ACVA. This is largely due to the reduction in the risk of reperfusion syndrome and the prevention of embolism due to the use of modern protection systems. Carotid  endarterectomy can be performed with comparable efficiency only when a tempo-rary shunt is placed in the internal carotid arteries in the absence of unstable atheroscle-rotic plaque. 

 INTRODUCTION Acute dizziness (AD) can be a manifestation of a large number of diseases, including both benign pathology and life-threatening conditions, particularly stroke. In his diagnostic search, the doctor can adhere to two tactics: the exclusion of peripheral vestibulopathies (the most common cause of AD), and the identification of symptoms of damage to the central nervous system.

AIM OF STUDY Comparison of instrumental research methods data with the clinical picture in patients with AD.

MATERIAl AND METHODS We examined 160 patients admitted to N.V. Sklifosovsky with the only or leading complaint of dizziness. In all patients neurological status was assessed, Dix–Hallpike (DH) and Pagnini–McClure  (PMC) positional maneuvers, Halmagyi–Curthoys (HC) test, duplex scan of brachiocephalic arteries, transthoracic echocardiography, computed  tomography, and magnetic resonance imaging were performed. brain. In  patients with suspected cardiogenic cause of dizziness, the diagnostic search included 24-hour Holter ECG monitoring.

RESUlTS The frequency of some symptoms differed in patients with acute cerebrovascular accidents (ACVA) and other diseases. In patients with stroke such symptom, as postural instability was statistically more frequently detected than in patients with other causes of dizziness (44% vs. 6%, p<0.05). The sensitivity and specificity of this symptom in patients with stroke was 44% and 94%, respectively. Horizontal nystagmus, changing direction depending on the gaze setting, was detected in 5 patients with ACVA (31%) and was not observed in patients with other diseases. The sensitivity of the symptom was 31% and the specificity was 100%.
Positional maneuvers of DH and PMC were positive only in patients with be-nign paroxysmal positional vertigo.

CONClUSION The main symptoms that make it possible to suspect a stroke in patients with acute dizziness are postural instability and horizontal nystagmus, which changes direction. The sensi-tivity and specificity of severe postural instability were 44% and 94%, and 31% and 100% for nystagmus  reversing direction. Positive Dix–Hallpike and Pagnini–McClure positional maneuvers can rule out stroke and establish the diagnosis of benign  paroxysmal positional vertigo in patients with acute dizziness. The Halmagyi–Curthoys test can be positive both in peripheral vestibulopathies (vestibular  neuronitis, Meniere’s syndrome, labyrinthitis), and in stroke in the basin 
of the anterior inferior cerebellar artery and cannot be used to confirm peripheral vestibulopathy. Holter daily monitoring of electrocardiography reveals cardiac conduction abnormalities as a cause of dizziness in patients  with episodes of non-systemic dizziness.

BACKGROUND Much attention is currently given to the issues of surgical treatment of common forms of secondary peritonitis, which is associated with unsuccessful results of treatment of this group of patients and the lack of a unified approach to surgical tactics among patients requiring repeated surgical interventions for adequate sanitation of the abdominal cavity.

AIM OF STUDY Improvement of the immediate results of treatment of patients with generalized secondary peritonitis by determining the approaches to choosing the optimal surgical tactics.

MATERIAl AND METHODS We analyzed the results of treatment of 220 patients with common forms of secondary peritonitis who were treated at the Elizavetinskaya hospital of St. Petersburg in the period from 2013 to 2019. The indicated patients were divided into two groups, comparable in terms of the main features, including the depth pathomorphological changes in the abdominal cavity, assessed by calculating abdominal cavity index (ACI) and the Mannheim peritonitis Index (MPI). The main group consisted of 109 patients, where developed algorithm was used, which supposed planned sanitation relaparotomies within up to 2 days in patients with high values of ACI and MPI. The comparison group included 111 patients who underwent sanitation interventions “on demand”, that is, in the presence of signs of persistence of the infectious process in the abdominal cavity. The results of treatment were compared by assessing the level and structure of postoperative mortality, the frequency of complications, and the length of stay in intensive care units and hospital. Mathematical-statistical data
processing, calculations of intensive and extensive coefficients of features, assessment of the statistical significance of differences in features for the studied groups were carried out.

RESUlTS The use of a differentiated approach to performing planned relaparotomy in patients with generalized peritonitis made it possible to reduce the overall mortality 1.7-fold (from 51.3 to 30.2%) (p=0.001) due to a decrease in the proportion of abdominal sepsis as a cause of unfavorable the outcome. No significant effect of the use of this algorithm on the frequency and structure of complications, as well as the duration of multiple organ failure, was found.

FINDINGS The use of planned relaparotomy among the selected patients helps to reduce postoperative mortality without significantly negatively affecting other treatment results.

 AIM OF STUDY To analyze the results of lateral extra-articular tenodesis (LET) of the semitendinosus muscle tendon (STMT) and iliotibial tract (ITT) in patients with severe anterior rotational instability of the knee joint during anatomical anterograde reconstruction of the anterior cruciate ligament (rACL) with a BTB graft.

MATERIAL AND METHODS We studied 138 patients with the Pivot shift test – 3+ and the Lachman test 2+ or 3+ degree after arthroscopic rACL with a BTB autograft. In 65 cases (47.1%) rACL was supplemented with LET of STMT (group 1), the remaining 73 patients (52.9%) – LET of ITT (group 2).

RESULTS According to IKDC-2000, KOSS and Lysholm-Tegner scores, the groups did not differ statistically. However, pain in the LET zone, LET failure with the appearance of the Pivot shift test – 1+, revision reconstructions – were more often observed in group 2 (p<0.05). Popliteal hematomas (p<0.001), longer operations (p<0.01) were more often observed in group 1.

CONCLUSION Lateral extra-articular tenodesis is a clinically effective addition to anatomical anterograde reconstruction of the anterior cruciate ligament with BTB autograft in patients with Pivot shift test 3+ and Lachman test 2+ or 3+.  However, a more reliable option is lateral extra-articular tenodesis of the 
semitendinosus muscle tendon. At the same time, lateral extra-articular  tenodesis of the iliotibial tract is a simpler, faster and more cost-effective  technique, still demonstrating good indicators of knee joint stability. 

BACKGROUND Structural damage to the brain substance in adults is one of the most common causes of epilepsy. Currently, such patients are prescribed drug therapy and/or surgery. With this approach, epileptic symptoms can persist in a significant proportion of patients (up to 30%, depending on the disease).

AIM OF STUDY To clarify the efficacy of stereotactic radiosurgery (STS) as part of the complex treatment of patients suffering from pharmacoresistant symptomatic epilepsy with hippocampal sclerosis, vascular malformations, and some benign tumors of the brain and its membranes.

MATERIAl AND METHODS Examination and radiosurgical treatment were carried out in 45 patients with various brain diseases accompanied by symptomatic epilepsy, provided that the previous conservative or surgical treatment was insufficiently effective. During the observation period, the frequency of seizures was assessed and the presence and nature of postoperative complications were recorded.

RESUlTS With a median follow-up of 30 months, good outcomes (class I–II according to J. Engel’s scale) were observed in 5 out of 8 patients with hippocampal sclerosis who underwent STS after  amygdaloghippocamplobectomy; seizure frequency decreased in all patients. Complications of STS were noted in 2 patients and had a transient nature. In the group of patients with meningiomas, in 4 out of 8 patients, seizures completely stopped, in 3 patients the frequency of seizures decreased by more than 90%, in another 1 the frequency of seizures decreased by 60%. There were no complications of STS during the observation period. In
intracerebral tumors (diffuse astrocytoma), Engel Ia outcome was observed in both patients. In the group of patients with cavernous angiomas, there were good outcomes (class I–II according to J. Engel’s scale) in 17 patients (85%). Deterioration (Engel IVc outcome) was observed in 1 patient (5%), 2 patients (10%) had complications of STS. In the group of patients with arteriovenous malformations, good outcomes (classes I–II according to J. Engel’s scale) were found in all 7 patients. The complication after STS was revealed in 1 patient.

CONClUSION The presented results confirm the high efficiency and low risk of side effects when using stereotactic radiosurgery in the complex treatment of patients with epilepsy associated with common structural brain lesions.

BACKGROUND Fractures of the proximal humerus are more common in older adults. Two options for surgical treatment of the same fractures are routinely performed — primary arthroplasty and osteosynthesis with metal fixators. Both methods are most effective in elderly patients for augmentation of the proximal humerus. For this purpose, methyl methacrylate cement or bone allo-/autografts are used. However, the incidence of unsatisfactory functional results after surgery remains high.

AIM OF STUDY To develop allogeneic graft to strengthen the proximal humerus in the osteosynthesis of a comminuted fracture with a lack of bone tissue which has osteoconductive properties and capable of being a carrier of biologically active substances.

MATERIAl AND METHODS The head, neck and portion of diaphysis of a fibula of a cadaver were used for a graft. The graft 6–8 cm long was formed and saturated with a collagen solution. Ten patients with 4-fragment fractures of the proximal humerus underwent surgery. X-rays and computed tomography of the operated joint were performed the day after surgery, and then, 6 weeks, 6 months, and one year after the surgery. The follow-up period ranged from 6 to 18 months.

RESUlTS When evaluating osteoconductive effect in cell culture during saturation with collagen, the content cells on the surface of bone was 5–8 thousand/cm2 and 16–18 thousand/cm2 on the sample, saturated with plasma and growth factors. The studied bone grafts were biocompatible and non-toxic for fibroblast culture. On the surface of the bone graft without collagen adhesion of minimum number of cells occurred. After saturation of the graft with collagen, the adhesive activity of cells on the bone matrix increased, which indicated the presence of an osteoconductive effect. The addition of plasma saturated with growth factors promoted an increase in the number of adhered cells; therefore, the graft can be used as a carrier of biologically active substances. Postoperative X-ray didn’t reveal secondary varus displacement of the head in any patient (except for ununiformed fracture case).

CONClUSION The developed graft is non-toxic, does not possess immunogenicity, has more pronounced osteoconductive properties in comparison with native bone allografts, which contributes to its colonization with cells. The use of such a graft in clinical practice makes it possible to achieve healing of the fracture and prevent secondary displacement of fragments. 

INTRODUCTION Determination of the degree of depression of consciousness in patients with brain damage upon admission to the intensive care unit and intensive therapy is a primary task. In order to carry out a quick and at the same time sufficiently complete assessment of this kind, in 1974 neurosurgeons Graham Teasdale and Bryan Jennett from the University of Glasgow developed an algorithm consisting of a sequential series of tests in the form of eye opening, speech and motor responses, called Glasgow Coma Scale. This scale has received worldwide recognition and for many decades has been the main one for determining the state of consciousness in the most severe patients with brain damage. The absence  of a validated version of this scale complicates its application in Russia, and the use of currently available versions that have not passed all the necessary  stages of validation distorts the originally intended meaning of the scale and does not allow obtaining reliable clinical results when examining patients with acute impairment of consciousness.

AIM OF STUDY Development of the official Russian­language version of the Glasgow Coma Scale, taking into account linguistic and cultural  characteristics (1st stage of the validation study).

MATERIAL AND METHODS The staff of Center for Validation of Health Status Questionnaires and Scales in Russia, Research Center of Neurology obtained consent from G. Teasdale to validate Glasgow Coma Scale in Russia. Two Russian­speaking professional certified translators in the field of  medicine performed a direct translation of the original English­language scale, and a reverse translation was carried out by native speakers with a medical education. Pilot study was performed in 15 patients with acute impairment of consciousness, two meetings of the expert committee were held (before and after pilot study).

RESULTS Based on the results of the first meeting of the expert commission, a linguistic and cultural adaptation of the text of the scale was carried out. During the pilot testing of the researchers did not have difficulties in understanding and interpreting instructions. As a result, the second meeting of the expert commission was held and the final Russian­language version was approved, which is presented in this article and is available on the website of Center for Validation of Health Status Questionnaires and Scales in Russia, Research Center of Neurology.

CONCLUSION For the first time, the Russian language version of the Glasgow Coma Scale was officially presented and recommended for use both in clinical and research practice in Russia and other Russian speaking countries. The next publication will highlight the result of assessing the psychometric properties (reproducibility, inter­expert agreement and sensitivity) of the Russian­language version of the scale.

AIM OF STUDY To compare the effectiveness of surgical treatment of patients with hypertensive intracerebral hematomas (ICHs) of subcortical location and methods of endoscopic aspiration and open removal.

MATERIAl AND METHODS The results of surgical treatment of 97 patients with hypertensive subcortical hematomas were analyzed. In group 1 (n=52),
endoscopic aspiration of the ICH was performed using a frameless  navigation station, in group 2 (n=45), open removal of the ICH was  performed using a microsurgical method.

RESUlTS Mortality among patients in the age group over 71 years after endoscopic aspiration of ICH was significantly lower than after open removal (30.8% and 60%, respectively). With a decrease in the level of wakefulness to sopor, the mortality rate with endoscopic removal was 50%, and with open intervention — 66.7%, with a decrease to coma — 100% in both groups. Among patients of the 1st group with the volume of ICH less than 40 cm3, the lethality was 11.1%, while in the 2nd group this indicator was almost 2 times higher — 20%. With endoscopic removal of an intrauterine device with a volume of 40 to 60 cm3, the mortality rate reached 14.3%, and with an open removal of a hematoma of the same volume, this indicator reached 30%, while the mortality rate in both groups was similar with a volume of an intrauterine device from 61 to 100 cm3 and amounted to 23.1% and 21.4% in the 1st and 2nd groups, respectively. The radicality of hematoma removal in the 1st and 2nd groups was 86.4% and 86%, respectively.

CONClUSION Endoscopic removal of hypertensive subcortical hematomas revealed a greater number of patients with good recovery, and postoperative mortality was 11.3% lower than with open removal, which, along with the  simplicity of execution and minimally invasiveness, indicates the safety and  efficiency of endoscopic aspiration for surgical treatment of patients with intracerebral hematomas of subcortical location. 

The analysis of the literature data allowed us to establish that today enteral nutrition (EN) is unanimously recognized by specialists as the preferred method of nutritional therapy, which significantly affects the course of critical conditions (CC). The use of EN now affects almost the entire nosology that forms the cohort of such patients. To the least extent, the scientific analysis of the possibilities of EN touched acute poisoning, where, given the special danger to life of their severe forms, there are great prospects for further research of this kind. It is especially emphasized that EN mainly in the first 24-48 hours from the onset of the disease mostly affects the achievement of positive results of treatment of CC, accompanied by an improvement in metabolic processes in organs and tissues. There is great interest in studying the pathogenesis of CC by assessing changes in homeostasis indicators using modern laboratory and instrumental control, which strengthens the scien-tific basis of EN. At the same time, it also contributes to the disclosure of his sanogenesis. Considering that, along with immunological shifts, the formation of oxidative stress and hemorheological disorders is of particular  importance in the pathogenesis of CC, being to a large extent involved in the development of endogenous intoxication and their irrevers-ibility, studies on EN in this field are promising, which, in our opinion, are still are very limited,  and in relation to hemorheology, according to the data available to us, are not represented at all. There are also no generalized up-to-date data on the economic component of EN. Further improvement of EN, as well as the  corresponding organizational measures, it seems, can bring this method to a  higher level of efficiency and, accordingly, safety, which, combined with the economic advantages of EN, will expand the possibilities of its  implementation in clinical practice.

AIM OF STUDY Standardization of staged treatment of patients with severe concomitant closed abdominal trauma.

 BACKGROUND This article is devoted to the discussion of a life-threatening and difficult to diagnose disease — cerebral venous thrombosis (CVT). The article lists clinical manifestations, features of diagnosis and treatment of CVT. Cerebral venous thrombosis is an emergency that requires a quick decision to start therapy in order to prevent the development of venous cerebral infarction, intracranial hemorrhage, severe disability and death. Cerebral venous thrombosis is a rare and rather difficult to recognize form of acute cerebrovascular accident (ACVA). Considering the variability of the clinical and radiological picture, as well as the large number of risk factors, CVT is a complex medical problem. Despite the fact that CVTs account for less than 1% of all ACVA, significant differences in treatment necessitate
the earliest possible differential diagnosis of CVT with arterial stroke. The diagnosis is often made with a delay due to a wide range of clinical manifestations, subacute onset of the disease, as well as low alertness of specialists in relation to CVT. In patients with cryptogenic stroke, CVT should be ruled out as a potential cause of stroke. Among other things, in the case of CVT, as in the case of thrombosis of the cerebral arteries, the establishment of the leading etiological factor is one of the priority tasks, the solution of which allows choosing the optimal means of secondary prevention. 

AIM OF STUDY Raising awareness of doctors of multidisciplinary hospitals about clinical manifestations, methods of diagnosis and treatment of CVT.

MATERIAl AND METHODS To achieve this goal, the results of domestic and foreign scientific research on the diagno-sis and treatment of CVT were analyzed. Literature searches were carried out in electronic search engines Scopus, eLibrary, PubMed using the keywords: cerebral venous thrombosis, cryptogenic stroke, intracerebral hemorrhage, anticoagulant therapy, neurological imaging in cerebral venous thrombosis. For the analysis, scientific articles published between 1828 and 2020 were selected. Thirty percent of the analyzed works on the subject of CVT are not older than 5 years.

CONClUSION Due to the various clinical manifestations and the absence of pathognomonic symptoms, neuroimaging plays a leading role in establishing the diagnosis. Early diagnosis of cerebral venous thrombosis and the use of anticoagulants lead to a decrease in disability and mortality. 

The pathology of the appendix remains one of the topical areas of abdominal surgery. Its rare diseases can be difficult to diagnose and treat, and are accompanied by the development of serious complications. One of them is  intussusception of the appendix to the cecum. Intussusception can be caused by previously undiagnosed primary lesions of the appendix. At the same time, it can simulate tumor and tumor-like formations of the cecum and lead to  diagnostic errors. The literature review provides modern data on the history of the study of the problem, the epidemiology of classification, the causes and mechanisms of the development of appendiceal intussusception, the methods of its diagnosis and treatment. 

The likelihood of life recovery in out-of-hospital cardiac arrest (OHCA) critically depends on the speed of providing care. Basic bystander cardiopulmonary resuscitation in case of OHCA and automatic external defibrillation greatly increase the chances of survival. To ensure a high level of readiness of the population to provide first aid (FA), effective legal regulation is required. The article presents the results of a comprehensive analysis of the current regulatory legal acts of the Russian Federation governing the provision of FA in case of OHCA, as well as domestic and foreign scientific publications dedicated to legal support in the field of FA. In particular, the issues of protection of persons providing FA from legal liability in case of harm to the victim are discussed, the obligations established by the legislation to provide FA and train FA, suggestions are made to optimize the relevant legal framework in order to increase the efficiency of first aid for OHCA and reduce mortality from OHCA in Russia.

 Today, there is a tendency to shift the focus of management from structural units to treatment and diagnostic processes in Russian healthcare institutions. To organize effective management of the treatment and diagnostic process, it is necessary to have its formalized description. This article presents the main results of a study conducted on the basis of N.V. Sklifosovsky Research Institute for Emergency Medicine, which was aimed at the development of an organizational and methodological approach to the description and standardization of treatment and diagnostic processes, taking into account the specifics of the activities of a multidisciplinary medical hospital.
When developing the organizational and methodological approach, the  methods of system analysis and modeling, factual data on the structure and  parameters of the treatment and diagnostic processes of the hospital, as well as the experience and expert opinions of the Institute staff were used. In the course of the study, the analysis of the organizational and economic  characteristics of the treatment and diagnostic processes was carried out and the requirements for the format of their description and the introduction of the notation into the practice of the hospital were formulated. Taking into account these requirements, the authors have developed and presented the format of the modified operogramme, which combines the ability to reflect both the logic of the process and the interaction of its participants, and the resource characteristics of the actions of the process. The article presents an organizational and methodological approach to the description and standardization of treatment and diagnostic processes, developed and tested by the authors, based on modified operogrammes and tables of summary resource characteristics.
The organizational part of the approach is based on the principle of maximum involvement of medical personnel of various categories in the description and standardization of processes through the formation of small groups, as well as on a system of multi-level examination of the developed models, checking them on statistical data to confirm the adequacy of expert assessments.
In N.V. Sklifosovsky Research Institute for Emergency Medicine 15 small  groups work on the main profiles of medical and diagnostic care on a  regular basis, more than 150 doctors are involved in the description and standardization, 232 models of complex medical and diagnostic processes, surgical interventions, active methods of treatment and diagnostics have been developed.
The operogrammes and summary tables of resource characteristics prepared using the above-described organizational and methodological approach, agreed within the hospital, become the basis for solving various organizational and economic tasks, including the development of internal recommendations, checklists, calculation of standard cost, resource planning, etc. 

The increase in the number of patients with complications of cardiovascular diseases and the need for early diagnosis of such complications and the early initiation of treatment already at the prehospital stage leads to an increasing  need for more frequent use of helicopter medical equipment, as well as for equipping aviation medical teams with highly qualified specialists. The  formation of a network of vascular invasive centers in the Moscow region,  modern equipment and its use in air ambulance conditions require constant improvement of skills among medical workers. All this undoubtedly leads to positive results, the mortality rate from heart attacks and strokes decreases, the duration of treatment and the period of rehabilitation of patients are  reduced. It should be noted that even 10 years ago, medical helicopters were used in the elimination of medical consequences in road accidents, fires and emergencies. Today, aviation medical teams are involved in more than 50% of cases with cardiovascular diseases, which undoubtedly speaks of the  prospects for the development of medical aviation in large cities.

 Today, the problem of spleen injury in children still appears relevant. The choice of diagnostics and treatment tactics at the present stage is far from being unified. The priority direction is the organ-preserving approach, which  is possible and justified in children, which significantly reduces surgical  aggression and prevents the likelihood of negative consequences of splenectomy. The choice of the optimal diagnostic method and  determination of safe treatment tactics was the purpose of our study. Thirty-nine injured children were treated in 2007–2019. The predominant cause of spleen injury was fall from height (64.1%). Echography was the main diagnostic method, which was performed around the clock. Splenectomy  was performed in 7 patients (17.9%), in 32 children (82.1%) the organ was preserved. One case (2.6%) was fatal. The analysis of our own results showed that the widespread use of echography, particularly by surgeons, is necessary in the emergency service and greatly simplifies the work. The developed local protocol for diagnosis and treatment is simple and accessible, since it is based on the interpretation of the main criteria, such as systemic hemodynamics and hemoperitoneum. Continued bleeding reasons diagnostic laparoscopy. With unstable hemodynamics, large hemoperitoneum, laparotomy is indicated.

AIM OF STUDY To develop a method for assessing the severity of obstructive jaundice (OJ) of non-neoplastic orogin on the basis of functional parameters of the liver and the activity of pathogenetic agents of hepatodepression.

MATERIAL AND METHODS Clinical and laboratory studies of 142 patients with breast cancer of non-tumor origin. The indicators of the functional state of the liver, the index of plasma toxicity for albumin, and the content of malondialdehyde (MDA) were evaluated.

RESUlTS Based on the assessment of a number of blood parameters - the content of total bilirubin (TB), the plasma toxicity index for albumin, the MDA level — the severity index of obstructive jaundice of non-neoplastic origin (SIOJ) was developed:
SIOJ = IT1/ITn + TB1/TB + 5(MDA1/MDAn)
where IT 1 is the plasma albumin toxicity index at the current moment, ITn is the normal albumin plasma toxicity index, TB1 is the current bilirubin  content, TBn is the normal bilirubin content, MDA1 is the current malondialdehyde content, MDAn is the normal value. The index less than 13 indicates a mild severity, 14–21 is moderate severity, 22 and higher indicates a severe degree of OJ. The method increases the objectivity of determining the severity of non-neoplastic origin by establishing the severity of liver damage and the processes underlying it.

CONClUSiON The suggested clinical and laboratory index allows the severity of obstructive jaundice to be objectively and quickly determined upon admission of a patient to the hospital and also adequate therapy to be initiated in case of severe degree for anticipation of possible post-operative complications, so the treatment should be focused on managing triggers of hepatodepression. The method is simple and available in medical institutions of various levels. The method is especially valuable when used in the dynamics of the early postoperative period.

INTRODUCTION Based on the Ministry of Emergency Situations data megapolises note an annual increase of the emergency situations (ES). The increase of an urban population in Russia up to 73% results in considerable human victims in big cities due to thermal injuries among others.

THE AIM of the present research is to analyze the structure of ES victims and the efficiency of the organization of a medical care for victims with thermal injuries in Moscow in 2016–2018.

MATERIAl AND METHODS We have held a retrospective analysis of 113 cases of patients of a Burn Center of Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health Department, and have studies the data of an automated informational analytical system named “Emergency Medicine” for 2016 2018.

RESUlTS For an absolute number of victims, fires are on the third place among different emergencies in Moscow, but on the pre­hospitalization stage, the biggest number of deaths are registered (38,2%). The number of patients with thermal injuries reaches 31% among all the patients in hospitals. We note a multi­factor and a combined character of injuries characterized by a high mortality rate (9,8%).

CONClUSION A present system of medical help for patients with thermal injuries, from the moment of ES fact to the hospitalization to multidisciplinary treatment­and­prophylactic organizations having an experience of specialized medical services, is a reliable and effective element of the health system. 

Crohn’s disease (CD) is nonspecific granulomatous inflammatory disease of all layers of the intestinal wall, characterized by a variety of clinical forms, heterogeneity of age groups of children and extraintestinal manifestations.  The diagnosis of the disease is difficult due to the presence of many  symptoms specific to a number of other surgical diseases of the abdominal cavity organs. This diagnosis is often made intraoperatively. In this study we report a case of treatment of a teenage girl who was admitted with complaints of a mass in the right iliac region extruding above the skin surface, instability of body weight, an increase in body temperature to 37.2° C for one month. As a result of laboratory and instrumental examination, the etiology was not established. Laparoscopy revealed abdominal infiltrate, consisting of the cecum, the distal ileum and a part of the greater omentum, tightly fixed to the anterior abdominal wall, which led to the destruction of
the peritoneum, muscle tissue and aponeurosis with further infiltration into the sub-cutaneous fat. Appendectomy and separation of the infiltrate were performed. After that, the girl was discharged due to the categorical refusal of the parents of the further treatment.
Twelve days later the patient had abdominal pain again, the dynamics of the pain syndrome intensified, the body temperature was febrile. After examination and detection of signs of peritonitis, emergency laparotomy, subtotal resection of the greater omentum, separation of the abdominal infiltrate (repeated), sanitation and drainage of the abdominal cavity were performed. During the surgery, the access to the abdominal cavity was performed with technical difficulties due to the fact that a conglomerate of intestinal loops and omentum was fixed to the anterior abdominal wall from the interior. The conglomerate was separated from the anterior abdominal wall by blunt dissection. The size of the conglomerate was up to 12–15 cm, formed by the transverse colon, the ileum and the greater omentum. The walls of the transverse colon and ileum in the area of the conglomerate had the cartilaginous density. For the purpose of further examination and determination of tactics for further treatment, the child was transferred to the Gastroenterology Department with a diagnosis of “Terminal ileitis. Purulent omentitis. Serous peritonitis. Mild normochromic anemia of mixed origin. Crohn’s disease?” After the additional examination in a specialized hospital, the diagnosis of CD was confirmed.

A case of acute focal myocardial injury in a polymorbid female patient with intact coronary arteries according to direct coronary angiography is reported. Acute focal myocardial injury was detected by ECG-synchronized  perfusion single-photon emission computed tomogra-phy (SPECT) of the  myocardium, and confirmed by the results of postmortem examination. The article also discusses the possibility of using perfusion SPECT to diagnose acute focal changes against the background of focal inflammatory myocardial infiltration. 

Acute chlorine gas poisoning leads to activation of the sympathetic nervous system and, as a consequence, dysfunction of the cardiovascular system (CVS). We report a clinical case of toxic myocardial injury with gaseous  chlorine. In a man with coronary artery disease and polypathy, toxic  myocardial injury mimicked acute coronary syndrome (ACS) and was accompanied by a large area of left ventricular microvascular dysfunction, which did not coincide with the areas of blood supply of altered coronary arteries; the dynamics of electrocardiographic changes resembled  myocardial stunning in Takotsubo syndrome (TS). The effect of chlorine on CVS, features of clinical and instrumental diagnostics and differentiation of primary / secondary CT and ACS are discussed. 

The facial nerve (fn) palsy is a disease of the peripheral nervous system that leads to aesthetic, organic and functional disorders. The causes of the disease are different, the most common is the idiopathic form bell’s palsy. With a conservative approach to therapy, up to 80% of patients note the complete recovery of the lost functions of facial muscles, the others have the likelihood of severe consequences. Electroneuromyography is used to assess the risk of a negative outcome of the disease. In cases of confirmation of severe nerve damage, surgical treatment is suggested. The article presents a clinical case of complete recovery of the function of facial muscles in a patient with severe damage to the a nerve and an unfavorable prognosis. The course of the disease, complications of bell’s palsy and methods of their correction are described. Timely correct choice of treatment tactics and prevention of complications minimizes negative consequences. When working with a patient, a differentiated approach is important depending on the clinical situation.

 Pneumoperitoneum normally occurs due to perforation of the hollow organ of the gastrointestinal tract, which is accompanied by the development of peritonitis. Cases of free gas without perforation and peritonitis are rare. Such situations are called “nonsurgical pneumoperitoneum”. This clinical case of a patient with pneumoperitoneum and no clinical picture of acute pathology in the abdominal cavity id reported in this article. Such patients should be carefully monitored by a surgeon to avoid unnecessary laparotomy.