2013 ¹ 1 Âîåííî-ìåäèöèíñêèé æóðíàë
ßÍÂÀÐÜ
2013
Ñáîð ðóêîâîäÿùåãî ñîñòàâà ìåäèöèíñêîé
ñëóæáû Âîîðóæåííûõ ñèë ÐÔ
 Ìîñêâå íà áàçå ÌÓÍÊÖ èì. Ï.Â.Ìàíäðûêà 20–21 äåêàáðÿ 2012 ã. ïðîâåäåí îïåðàòèâ-íî-ñïåöèàëüíûé ñáîð ïî ïîäâåäåíèþ èòîãîâ ðàáîòû ìåäèöèíñêîé ñëóæáû Âîîðóæåííûõ ñèë Ðîññèéñêîé Ôåäåðàöèè. Íà îòêðûòèè ñáîðà ñ äîêëàäîì «Îñíîâíûå èòîãè ïîäãîòîâêè ìåäèöèíñêîé ñëóæáû Âîîðóæåííûõ ñèë Ðîññèéñêîé Ôåäåðàöèè â 2012 ã. è çàäà÷è, ñòîÿùèå ïåðåä íåé â 2013 ã.» âûñòóïèë âðèä íà÷àëüíèêà Ãëàâíîãî âîåííî-ìåäèöèíñêîãî óïðàâëåíèÿ ÌÎ ÐÔ ïîëêîâíèê ìåäèöèíñêîé ñëóæáû Â.À.Íîâèêîâ. Ó÷àñòíèêè ñáîðà çàñëóøàëè äîêëàäû «Ïåðñïåêòèâû ðàçâèòèÿ ìåäèöèíñêîé ñëóæáû Âîîðóæåííûõ ñèë ÐÔ â ñîâðåìåííûõ óñëîâèÿõ» (âðèä íà÷àëüíèêà 1 óïðàâëåíèÿ ÃÂÌÓ ÌÎ ÐÔ ïîëêîâíèê ìåäèöèíñêîé ñëóæáû À.Þ.Âëàñîâ), «Àíàëèç äåÿòåëüíîñòè âîåííî-ìåäèöèíñêèõ ó÷ðåæäåíèé çà 2012 ã. Îñíîâíûå ïðîáëåìíûå âîïðîñû è ïóòè èõ ðåøåíèÿ» (âðèî íà÷àëüíèêà 2 óïðàâëåíèÿ ÃÂÌÓ ÌÎ ÐÔ ïîëêîâíèê ìåäèöèíñêîé ñëóæáû À.Ñ.Êëèìîâ), «Èòîãè îðãàíèçàöèè îáåñïå÷åíèÿ ìåäèöèíñêîé òåõíè-êîé è èìóùåñòâîì Âîîðóæåííûõ ñèë ÐÔ â 2012 ã. Çàäà÷è íà 2013 ãîä» (íà÷àëüíèê 3 óïðàâ-ëåíèÿ ÃÂÌÓ ÌÎ ÐÔ ïîëêîâíèê ìåäèöèíñêîé ñëóæáû À.È.Ñåëèí), «Èòîãè îáåñïå÷åíèÿ ñàíèòàðíî-ýïèäåìèîëîãè÷åñêîãî áëàãîïîëó÷èÿ â ÂÑ ÐÔ: ïðîáëåìíûå âîïðîñû è ïóòè ðåøåíèÿ, ïåðñïåêòèâû» (íà÷àëüíèê 736-ãî Ãëàâíîãî öåíòðà ãîñóäàðñòâåííîãî ñàíèòàðíî-ýïèäåìèîëîãè÷åñêîãî íàäçîðà – ãëàâíûé ãîñóäàðñòâåííûé ñàíèòàðíûé âðà÷ ÌÎ ÐÔ ïîëêîâíèê ìåäèöèíñêîé ñëóæáû Ý.Ï.Ñîëîâåé), «Ïðèâåäåíèå îðãàíîâ âîåííî-âðà÷åáíîé ýêñïåðòèçû â ñîîòâåòñòâèå ñ çàêîíîäàòåëüíûìè è íîðìàòèâíûìè àêòàìè Ðîññèéñêîé Ôåäåðàöèè» (íà÷àëüíèê ÃÖ ÂÂÝ ÌÎ ÐÔ ïîëêîâíèê ìåäèöèíñêîé ñëóæáû Ê.Ý.Êóâøèíîâ).  ðàáîòå ñáîðà ó÷àñòâîâàëè ãëàâíûå ìåäèöèíñêèå ñïåöèàëèñòû ÌÎ ÐÔ, îôèöåðû ÃÂÌÓ ÌÎ ÐÔ, ðóêîâîäèòåëè ìåäèöèíñêîé ñëóæáû âèäîâ ÂÑ, ðîäîâ âîéñê, âîåííûõ îêðóãîâ, ÂÌåäÀ èì. Ñ.Ì.Êèðîâà, ìåäèöèíñêèõ âîèíñêèõ ÷àñòåé, ó÷ðåæäåíèé è îðãàíèçàöèé.Àäðåñ ðåäàêöèè: 194044, Ñàíêò-Ïåòåðáóðã, óë. Àêàäåìèêà Ëåáåäåâà, ä. 6 Òåë. (812) 292-33-46 Êîðïóíêò â Ìîñêâå: 119160, Ìîñêâà, ðåäàêöèÿ «Âîåííî-ìåäèöèíñêîãî æóðíàëà» Òåë./ôàêñ: (495) 656-33-41 ÅÆÅÌÅÑß×ÍÛÉ ÒÅÎÐÅÒÈ×ÅÑÊÈÉ È ÍÀÓ×ÍÎ-ÏÐÀÊÒÈ×ÅÑÊÈÉ ÆÓÐÍÀË ÌÈÍÈÑÒÅÐÑÒÂÀ ÎÁÎÐÎÍÛ ÐÎÑÑÈÉÑÊÎÉ ÔÅÄÅÐÀÖÈÈ
Non scholae, sed vitae discimus!
ÐÅÄÀÊÖÈÎÍÍÀß ÊÎËËÅÃÈß: Ì.Â.Ïîääóáíûé (ãëàâíûé ðåäàêòîð) À.Í.Áåëüñêèõ Â.Â.Áóçóíîâ (îòâåòñòâåííûé ñåêðåòàðü) À.Þ.Âëàñîâ Ë.Ë.Ãàëèí (çàìåñòèòåëü ãëàâíîãî ðåäàêòîðà) À.Í.Ãðåáåíþê Â.Â.Èâàíîâ Î.Â.Êàëà÷åâ À.À.Êàëìûêîâ À.Á.Ëåîíèäîâ À.Í.Ìèðîíåíêî Þ.Â.Ìèðîøíè÷åíêî Â.À.Íîâèêîâ È.Ì.Ñàìîõâàëîâ À.È.Ñåëèí Ý.Ï.Ñîëîâåé Þ.Ø.Õàëèìîâ Â.Í.Öûãàí Â.Ê.Øàìðåé À.Ì.Øåëåïîâ ÐÅÄÀÊÖÈÎÍÍÛÉ ÑÎÂÅÒ:
Èçäàåòñÿ ñ 1823 ãîäà
2013 * ßÍÂÀÐÜ
Ò. 334 * ¹ 1
ÌÎÑÊÂÀ ÈÇÄÀÒÅËÜÑÊÈÉ ÄÎÌ «ÊÐÀÑÍÀß ÇÂÅÇÄÀ» Ñ.À.Áåëÿêèí (Êðàñíîãîðñê) Ï.Ã.Áðþñîâ (Ìîñêâà) À.À.Áóäêî (À.Í.) Â.Â.Âàëåâñêèé (Ñ.-Ïåòåðáóðã) Ñ.Ô.Ãîí÷àðîâ (Ìîñêâà) Â.Â.Äîáðæàíñêèé (Ìîñêâà) Å.Â.Èâ÷åíêî (Ñ.-Ïåòåðáóðã) È.Á.Ìàêñèìîâ (Ìîñêâà) È.Ã.Ìîñÿãèí (Ñ.-Ïåòåðáóðã) Ý.À.Íå÷àåâ (Ìîñêâà) Ï.Â.Ïèí÷óê (Ìîñêâà) Â.Á.Ñèìîíåíêî (Ìîñêâà) À.ß.Ôèñóí (Ìîñêâà) È.Ì.×èæ (Ìîñêâà) Àäðåñ â ñåòè Èíòåðíåò: http://sc.mil.ru/social/media/ magazine/more.htm?id=8753 @morfOrgInfoÎêàçàíèå ìåäèöèíñêîé ïîìîùè
è ëå÷åíèå ëåãêîðàíåíûõ
â âîîðóæåííîì êîíôëèêòå
Ìíîãîïðîôèëüíûå
àìáóëàòîðíî-ïîëèêëèíè÷åñêèå ó÷ðåæäåíèÿ
â òåððèòîðèàëüíîé ñèñòåìå
ìåäèöèíñêîãî îáåñïå÷åíèÿ
Ñïåöèàëèçèðîâàííàÿ ìåäèöèíñêàÿ
ïîìîùü ïðè îñòðîì êîñòíîìîçãîâîì
ñèíäðîìå ðàäèàöèîííîé ýòèîëîãèè
Ìåäèöèíñêàÿ ïîìîùü èíôåêöèîííûì
áîëüíûì íà äîãîñïèòàëüíîì ýòàïå
«Ëåãêîå âîäîëàçà»: îñîáåííîñòè
ðåìîäåëèðîâàíèÿ ñèñòåìû îðãàíîâ
äûõàíèÿ ó àêâàíàâòîâ ÂÌÔ
Íàó÷íî-ìåäèöèíñêèå èññëåäîâàíèÿ
â âîåííî-ìîðñêîì ôëîòå ÑØÀ
ÑONTENTS
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Ëå÷åáíî-ïðîôèëàêòè÷åñêèå
âîïðîñû Prophylaxis and treatment
Îðãàíèçàöèÿ ìåäèöèíñêîãî îáåñïå÷åíèÿ Âîîðóæåííûõ ñèë
Organization of medical support of the Armed Forces
25 39 19 33 Ýïèäåìèîëîãèÿ è èíôåêöèîííûå áîëåçíè Epidemiology
and infectious diseases
Samokhvalov I.M., Kotenko P.K., Severin V.V. – Problems of organization of surgical care to the wounded in a modern armed con-flict: surgical care to the walking wounded in armed conflicts (Report 2)
Belousova O.D., Gaidash A.A., Tolmachyov I.A., Ivchenko E.V., Golubok A.O., Levichev V.V., Mukhin I.S., Zhukov M.V., Belousov I.S., Tka-chuk I.V. – Structure of cytosolic mem-brane and chemical composition of red blood cell during the early period of wound damage according to scanning probe mi-croscopy
Ìåäèöèíà ýêñòðåìàëüíûõ ñèòóàöèé
Medicine of extreme situations
Khalimov Yu.Sh., Grebenyuk À.N., Legeza V.I., Karamullin M.A., Salukhov V.V. – Modern condition and prospects of improvement of the specialized medical aid of acute marrow failure of radiant etiology Byzov N.V., Plekhanov V.N. – Endoscopic diagnosis of local chemical burn of mucous coat of stomach, induced with the aim of simulation of gastric ulcer
Zhdanov K.V., Zakharenko S.M., Kovalen-ko A.N. – Delivery of health care to conta-gious patients during the pre-hospital stage Ñàìîõâàëîâ È.Ì., Êîòåíêî Ï.Ê., Ñåâåðèí Â.Â. – Ïðîáëåìû îðãàíèçàöèè îêàçàíèÿ õè-ðóðãè÷åñêîé ïîìîùè ðàíåíûì â ñîâðå-ìåííîé âîéíå: îêàçàíèå ìåäèöèíñêîé ïî-ìîùè è ëå÷åíèå ëåãêîðàíåíûõ â âîîðó-æåííîì êîíôëèêòå (Ñîîáùåíèå âòîðîå)
Eloev M.S., Kli pak V.M. – Experience, problems and prospects of development of multifield outpatient department in area system of medical supply of Moscow region Åëîåâ Ì.Ñ., Êëèïàê Â.Ì. – Îïûò, ïðî-áëåìû è ïåðñïåêòèâû ðàçâèòèÿ ìíîãî-ïðîôèëüíîãî àìáóëàòîðíî-ïîëèêëèíè-÷åñêîãî ó÷ðåæäåíèÿ â òåððèòîðèàëüíîé ñèñòåìå ìåäèöèíñêîãî îáåñïå÷åíèÿ â Ìîñêîâñêîì ðåãèîíå 9 Áåëîóñîâà Î.Ä., Ãàéäàø À.À., Òîëìà÷¸â È.À., Èâ÷åíêî Å.Â., Ãîëóáîê À.Î., Ëåâè÷åâ Â.Â., Ìóõèí È.Ñ., Æóêîâ Ì.Â., Áåëîóñîâ È.Ñ., Òêà÷óê È.Â. – Ñòðóêòóðà öèòîïëàçìà-òè÷åñêèõ ìåìáðàí è õèìè÷åñêèé ñîñòàâ ýðèòðîöèòîâ â ðàííèé ïåðèîä ðàíåâûõ ïîâðåæäåíèé ïî äàííûì ñêàíèðóþùåé çîíäîâîé ìèêðîñêîïèè Õàëèìîâ Þ.Ø., Ãðåáåíþê À.Í., Ëåãåçà Â.È., Êàðàìóëëèí Ì.À., Ñàëóõîâ Â.Â. – Ñîâðå-ìåííîå ñîñòîÿíèå è ïåðñïåêòèâû ñîâåð-øåíñòâîâàíèÿ ñïåöèàëèçèðîâàííîé ìåäè-öèíñêîé ïîìîùè ïðè îñòðîì êîñòíîìîç-ãîâîì ñèíäðîìå ðàäèàöèîííîé ýòèîëîãèè Áûçîâ Í.Â., Ïëåõàíîâ Â.Í. – Ýíäîñêîïè-÷åñêàÿ äèàãíîñòèêà ëîêàëüíîãî õèìè-÷åñêîãî îæîãà ñëèçèñòîé îáîëî÷êè æåëóäêà, âûçâàííîãî ñ öåëüþ ñèìóëÿ-öèè ÿçâû æåëóäêà Æäàíîâ Ê.Â., Çàõàðåíêî Ñ.Ì., Êîâàëåíêî À.Í. – Îêàçàíèå ìåäèöèíñêîé ïîìîùè èí-ôåêöèîííûì áîëüíûì íà äîãîñïèòàëü-íîì ýòàïå
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«Âîåííî-ìåäèöèíñêèé æóðíàë», 1’2013 79 74 Èç èñòîðèè âîåííîé ìåäèöèíûFrom the history of military medicine Ïî ñòðàíèöàì çàðóáåæíîé
ìåäèöèíñêîé ïå÷àòè
From the foreign medical publications Êðàòêèå ñîîáùåíèÿ Brief reports
Agapitov A.A., Aleinikov S.I., Bolekhan V.N., Ivchenko E.V., Krassiy A.B., Nagibovich O.A., Petrov S.V., Rezvantsev M.V., Soldatov E.A., Shalakhin R.A., Sheppli E.V. – Medical Research in the US Armed Forces (Re-port 4)
Kim A.P. – Ussuriysk military hospital celebrates 130th anniversary
Galin L.L. – Surgeon, poet, journalist… (The 80th anniversary of the birth of V.V.Belozerov)
Kuzmenko I.E. – Anniversary of the medi-cal department of the Federal Directorate for Safe Storage and Destruction of Chemical Weapons
83 66 44 Àâèàöèîííàÿ
è âîåííî-ìîðñêàÿ ìåäèöèíà Air and navy medicine
TchumakovA.V., Sukhoroslova I.E., Sharova N.V., Svistov A.S., Neustroyev A.P., Makiyev R.G., Alanichev A.E. – «Diver’s lung»: features of respiratory system remodeling at navy aquanauts in long-term period after deep saturation dives ×óìàêîâ À.Â., Ñóõîðîñëîâà È.Å., Øàðî-âà Í.Â., Ñâèñòîâ À.Ñ., Íåóñòðîåâ À.Ï., Ìàêè-åâ Ð.Ã., Àëàíè÷Ìàêè-åâ À.Å. – «Ëåãêîå âîäîëàçà»: îñîáåííîñòè ðåìîäåëèðîâàíèÿ ñèñòåìû îðãàíîâ äûõàíèÿ ó àêâàíàâòîâ ÂÌÔ â ïåðèîä îòäàëåííûõ ïîñëåäåéñòâèé ãëóáîêîâîäíûõ íàñûùåííûõ ñïóñêîâ Àãàïèòîâ À.À., Àëåéíèêîâ Ñ.È., Áîëåõàí Â.Í., Èâ÷åíêî Å.Â., Êðàññèé À.Á., Íàãèáîâè÷ Î.À., Ïåòðîâ Ñ.Â., Ðåçâàíöåâ Ì.Â., Ñîëäàòîâ Å.À., Øàëàõèí Ð.À., Øåïïëè Å.Â. – Íàó÷íî-ìåäèöèíñêèå èññëåäîâàíèÿ â âîîðóæåí-íûõ ñèëàõ ÑØÀ (Ñîîáùåíèå ÷åòâåðòîå) Êèì À.Ï. – Óññóðèéñêîìó âîåííîìó ãîñïèòàëþ – 130 ëåò Ãàëèí Ë.Ë. – Âîåííî-ìîðñêîé âðà÷, ïîýò, æóðíàëèñò (Ê 80-ëåòèþ ñî äíÿ ðîæäåíèÿ Â.Â.Áåëîçåðîâà) Êóçüìåíêî È.Å. – Þáèëåé ìåäèöèíñêîé ñëóæáû Ôåäåðàëüíîãî óïðàâëåíèÿ ïî áåçîïàñíîìó õðàíåíèþ è óíè÷òîæåíèþ õèìè÷åñêîãî îðóæèÿ 49 ÑONTENTS Îáðàùàåì âíèìàíèå àâòîðîâ íà íåîáõîäèìîñòü óêàçûâàòü, êðîìå îáùèõ ïàñïîðòíûõ äàííûõ íà êàæäîãî àâòîðà ñòàòüè, èõ ýëåêòðîííûå àäðåñà (e-mail) è âîèíñêèå çâàíèÿ (â ò. ÷. çàïàñà, â îòñòàâêå) Ëåíòà íîâîñòåé 88 News feed Îôèöèàëüíûé îòäåë 86 Official communications Õðîíèêà 94 Chronicle
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ÎÐÃÀÍÈÇÀÖÈß ÌÅÄÈÖÈÍÑÊÎÃÎ
ÎÁÅÑÏÅ×ÅÍÈß ÂÎÎÐÓÆÅÍÍÛÕ ÑÈË
© ÊÎËËÅÊÒÈ ÀÂÒÎÐÎÂ, 2013 ÓÄÊ 616-001.45-057.36-089Ïðîáëåìû îðãàíèçàöèè îêàçàíèÿ õèðóðãè÷åñêîé
ïîìîùè ðàíåíûì â ñîâðåìåííîé âîéíå: îêàçàíèå
ìåäèöèíñêîé ïîìîùè è ëå÷åíèå ëåãêîðàíåíûõ
â âîîðóæåííîì êîíôëèêòå (Ñîîáùåíèå âòîðîå)*
ÑÀÌÎÕÂÀËÎÂ È.Ì., çàñëóæåííûé âðà÷ ÐÔ, ïðîôåññîð, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû çàïàñà ([email protected]) ÊÎÒÅÍÊÎ Ï.Ê., ïðîôåññîð, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû çàïàñà ÑÅÂÅÐÈÍ Â.Â., ïîëêîâíèê ìåäèöèíñêîé ñëóæáû Âîåííî-ìåäèöèíñêàÿ àêàäåìèÿ èì. Ñ.Ì.Êèðîâà, Ñàíêò-ÏåòåðáóðãSamokhvalov I.M., Kotenko P.K., Severin V.V. – Problems of îrganization of surgical care to the wounded
in a modern armed conflict: surgical care to the walking wounded in armed conflicts (Report 2).
There are two triage groups of the walking wounded in a medical company of a brigade/special-purpose medical team: those returning to fighting role and those who have to be evacuated to level 3 echelon of care. The main purposes of surgical care of the walking wounded in the 3rd echelon of care are the following: diagnosis of injury pattern ruling out severe damages and separation of the independent category of the walking wounded. There is medical evacuation of the walking wounded from the 3rd echelon to the 4th echelon deployed in a combat zone. The walking wounded who needs less than 30 days of staying in hospital are evacuated to the garrison military hospitals and medical treatment facilities subordinated to a district military hospital. The wounded with the prolonged period of hospitalization (more than 30 days) are evacuated toward the district military hospital. Treatment of the walking wounded should be accomplished in the military district where the armed conflict goes on.
K e y w o r d s: walking wounded, surgical care, combat environments, medical evacuation.
À
êòóàëüíîñòü ïðîáëåìû ëå÷åíèÿ ëåãêîðàíåíûõ (ËÐ) îïðåäåëÿåòñÿ èõ âû-ñîêîé ÷àñòîòîé (áîëåå 50% â ñòðóêòóðå ñà-íèòàðíûõ ïîòåðü õèðóðãè÷åñêîãî ïðîôèëÿ) è îòñóòñòâèåì îáùåïðèíÿòîé êîíöåïöèè îðãàíèçàöèè îêàçàíèÿ ìåäèöèíñêîé ïîìî-ùè ËÐ â ñîâðåìåííîé ñèñòåìå ëå÷åáíî-ýâà-êóàöèîííîãî îáåñïå÷åíèÿ âîéñê/ñèë â âî-åííûõ êîíôëèêòàõ ðàçíîãî óðîâíÿ. Äî íàñòîÿùåãî âðåìåíè îðãàíèçàöèÿ îêàçàíèÿ ìåäèöèíñêîé ïîìîùè è ëå÷å-íèÿ ËÐ îñíîâûâàåòñÿ ãëàâíûì îáðàçîì íà îïûòå, íàêîïëåííîì â ãîäû Âåëèêîé Îòå÷åñòâåííîé âîéíû 1941–1945 ãã. Òîãäà èñïîëüçîâàëè àêòèâíóþ õèðóðãè-÷åñêóþ òàêòèêó, íàïðàâëåííóþ íà ñêî-ðåéøåå âîçâðàùåíèå ËÐ â ñòðîé. Òàê, ïî äàííûì È.À.Êðèâîðîòîâà, â ïåðâûé ãîä âîéíû àìïóòàöèþ ïàëüöåâ ïðîèçâîäèëè òîëüêî â 30% ñëó÷àåâ ðàíåíèé êèñòè, à â ïîñëåäíèé ãîä åå ÷àñòîòà âîçðîñëà äî 70% [3]. Ïîäîáíûé ïîäõîä áûë îïðàâäàí â âîéíå, ñîïðîâîæäàâøåéñÿ êðàéíåé ñòå-ïåíüþ íàïðÿæåíèÿ ðåñóðñîâ ãîñóäàðñòâà, â ò. ÷. è ëþäñêèõ, ÷òî ïîðîäèëî ëåòó÷óþ ôðàçó: «Âåëèêóþ Îòå÷åñòâåííóþ âîéíó âûèãðàëè ëåãêîðàíåíûå» [1]. Ñèñòåìû ëå÷åíèÿ ËÐ íåò è çà ðóáå-æîì: âîåííûå ìåäèêè ÂÑ ÍÀÒÎ âêëþ-÷àþò «õîäÿ÷èõ» ðàíåíûõ â ãðóïïó «ìè-íèìàëüíûõ» ïîâðåæäåíèé (T3 – delayed èëè minimal), ïîëó÷àþùèõ ìåäèöèíñêóþ ïîìîùü â îòñðî÷åííîì ïîðÿäêå; îðãà-íèçàöèè ñïåöèàëüíîãî îêàçàíèÿ õè-ðóðãè÷åñêîé ïîìîùè ãðóïïå ËÐ («return to duty») íå ïðåäóñìàòðèâàåòñÿ [6]. Ïðè ýòîì â ñîâðåìåííûõ âîîðóæåííûõ êîíôëèêòàõ ñîçäàþòñÿ áëàãîïðèÿòíûå óñ-ëîâèÿ îêàçàíèÿ ìåäèöèíñêîé ïîìîùè è ëå÷åíèÿ ËÐ ñ ïðèìåíåíèåì ýôôåêòèâíûõ òåõíîëîãèé, íàïðàâëåííûõ íà äîñòèæåíèå ìàêñèìàëüíî âîçìîæíûõ ôóíêöèîíàëüíûõ ðåçóëüòàòîâ ëå÷åíèÿ è áûñòðîé âîåííî-ïðî-ôåññèîíàëüíîé ðåàáèëèòàöèè. *Ñîîáùåíèå ïåðâîå ñì.: Âîåí.-ìåä. æóðí. – 2012. – Ò. 333, ¹ 12. – Ñ. 4–11.«Âîåííî-ìåäèöèíñêèé æóðíàë», 1’2013
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ÎÐÃÀÍÈÇÀÖÈß ÌÅÄÈÖÈÍÑÊÎÃÎ ÎÁÅÑÏÅ×ÅÍÈß ÂÎÎÐÓÆÅÍÍÛÕ ÑÈË Íåñìîòðÿ íà îãðàíè÷åííûå ìàñøòà-áû ñîâðåìåííûõ âîåííûõ êîíôëèêòîâ è óìåíüøåíèå ÷èñëåííîñòè âîéñê, áûñòðîå âîçâðàùåíèå â ñòðîé ìàêñèìàëüíî âîç-ìîæíîãî ÷èñëà ïðîôåññèîíàëüíî ïîäãî-òîâëåííûõ ðàíåíûõ âîåííîñëóæàùèõ îñòàåòñÿ âàæíåéøåé çàäà÷åé âîåííî-ìå-äèöèíñêîé ñëóæáû. Îíà ðåàëèçóåòñÿ, ïðåæäå âñåãî, çà ñ÷åò êîíòèíãåíòà ËÐ, ïîñêîëüêó òÿæåëîðàíåíûì îñóùåñòâëÿ-þòñÿ ìåðîïðèÿòèÿ ïî ñïàñåíèþ æèçíè è ìàêñèìàëüíîìó ñíèæåíèþ ñîöèàëüíûõ ïîñëåäñòâèé ïîëó÷åííîé áîåâîé òðàâìû âíå çàâèñèìîñòè îò ñðîêîâ ëå÷åíèÿ. Ñî÷åòàíèå èçìåíèâøèõñÿ óñëîâèé äåÿòåëüíîñòè âîéñê è ìåäèöèíñêîé ñëóæ-áû, à òàêæå íåáëàãîïðèÿòíîé äåìîãðàôè-÷åñêîé ñèòóàöèè, ñëîæèâøåéñÿ â Ðîññèè íà ðóáåæå XX–XXI ââ., òðåáóåò ïðîäîë-æåíèÿ ðàçðàáîòêè ïðîáëåì îêàçàíèÿ ìå-äèöèíñêîé ïîìîùè è ëå÷åíèÿ ËÐ íà ýòà-ïàõ ìåäèöèíñêîé ýâàêóàöèè. Ïðèìåíå-íèå «îñòàòî÷íîãî» ïðèíöèïà ïðè îðãà-íèçàöèè îêàçàíèÿ ìåäèöèíñêîé ïîìîùè è ëå÷åíèÿ ËÐ ïðèíöèïèàëüíî îøèáî÷-íî ââèäó âûñîêîãî çíà÷åíèÿ äàíîøèáî÷-íîãî êîíòèíãåíòà äëÿ âîñïîëíåíèÿ óáûëè âîéñê è êðàéíåé ñòåïåíè åãî ñîöèàëü-íîé âçðûâîîïàñíîñòè. Â Û Â Î Ä Û 1. Ïðè ïðîâåäåíèè ìåäèöèíñêîé ñîðòèðîâêè ËÐ â ìåäèöèíñêîé ðîòå áðè-ãàäû/îìåäî ÑïÍ, îìåäî àìåäáð âûäå-ëÿþòñÿ ñîõðàíèâøèå áîåñïîñîáíîñòü âîåííîñëóæàùèå ñ ïîâðåæäåíèÿìè, íå ïðè÷èíèâøèìè âðåäà çäîðîâüþ è íå ÿâëÿþùèìèñÿ ñòðàõîâûìè ñëó÷àÿìè (ïîäëåæàò âîçâðàùåíèþ â ñâîå âîèí-ñêîå ïîäðàçäåëåíèå/âîéñêîâóþ ÷àñòü), è ËÐ, íóæäàþùèåñÿ â äàëüíåéøåé ýâà-êóàöèè â ÌÂÃ. 2. Îñíîâíûìè çàäà÷àìè îêàçàíèÿ ìåäèöèíñêîé ïîìîùè è ëå÷åíèÿ ËÐ â ÌÂà ââèäó êðàòêîâðåìåííîñòè ïðåáû-âàíèÿ íà äàííîì ýòàïå ìåäèöèíñêîé ýâà-êóàöèè (íå áîëåå 1–1,5 ñóò) ÿâëÿþòñÿ äèàãíîñòèêà õàðàêòåðà ðàíåíèÿ ñ èñêëþ-÷åíèåì òÿæåëûõ ïîâðåæäåíèé, â ò. ÷. ñ îñìîòðîì â ïåðåâÿçî÷íîé äëÿ ïîñòàíîâ-êè ïîêàçàíèé ê îòñðî÷åííûì îïåðàöè-ÿì, âûÿâëåíèÿ ðàçâèâàþùèõñÿ îñëîæíå-íèé, à òàêæå âûäåëåíèå ñàìîñòîÿòåëüíî-ãî ïîòîêà ËÐ. 3. Ýâàêóàöèÿ ËÐ èç ÌÂà îñóùåñòâ-ëÿåòñÿ â ãîñïèòàëè âîåííîãî îêðóãà, íà òåððèòîðèè îòâåòñòâåííîñòè êîòîðîãî âåäóòñÿ áîåâûå äåéñòâèÿ. ËÐ ñî ñðîêàìè ëå÷åíèÿ äî 30 ñóò ýâàêóèðóþòñÿ â ãàðíè-çîííûå (áàçîâûå) ôèëèàëû è ñòðóêòóð-íûå ïîäðàçäåëåíèÿ ÎÂÃ; ËÐ ñî ñðîêàìè ëå÷åíèÿ, ïðåâûøàþùèìè 30 ñóò, ýâàêóè-ðóþòñÿ â ÎÂÃ. Ïðè ýñêàëàöèè âîåííîãî êîíôëèêòà öåëåñîîáðàçíà ñïåöèàëèçàöèÿ îäíîãî èëè íåñêîëüêèõ âîåííûõ ãîñïè-òàëåé äëÿ ëå÷åíèÿ ËÐ. 4. Ëå÷åíèå ËÐ â õîäå ëîêàëèçàöèè è ëèêâèäàöèè âîîðóæåííîãî êîíôëèêòà äîëæíî áûòü çàâåðøåíî â ïðåäåëàõ âî-åííîãî îêðóãà. Ýâàêóàöèÿ ëåãêîðàíåíûõ â âîåííûå ëå÷åáíî-ïðîôèëàêòè÷åñêèå ó÷ðåæäåíèÿ Öåíòðà äîëæíà ðàñöåíèâàòü-ñÿ êàê ãðóáûé äåôåêò îðãàíèçàöèè ñèñ-òåìû ëå÷åáíî-ýâàêóàöèîííîãî îáåñïå÷å-íèÿ âîéñê/ñèë.Ëèòåðàòóðà
1. Áàãðàìÿí È.Õ. Âñåìåðíî ïîâûøàòü áîå-ãîòîâíîñòü ìåäèöèíñêîé ñëóæáû // Âîåí.-ìåä. æóðí. – 1963. – ¹ 5. – Ñ. 5. 2. Ãóìàíåíêî Å.Ê., Áîÿðèíöåâ Â.Â., Ñóâîðîâ Â.Â., Ñóïðóí Ò.Þ. Îáúåêòèâíàÿ îöåíêà òÿæå-ñòè áîåâîé õèðóðãè÷åñêîé òðàâìû: Âîåííî-ïîëåâàÿ õèðóðãèÿ ëîêàëüíûõ âîéí è âîîðó-æåííûõ êîíôëèêòîâ / Ïîä ðåä. Å.Ê.Ãóìàíåíêî, È.Ì.Ñàìîõâàëîâà. – Ì.: ÃÝÎÒÀÐ-Ìåäèà, 2010. – Ñ. 179–230. 3. Êðèâîðîòîâ È.À. Îñíîâíûå èòîãè ëå÷å-íèÿ ëåãêîðàíåíûõ â ãîäû Âåëèêîé Îòå÷å-ñòâåííîé âîéíû 1941–1945 ãã.: Îò÷åò ÍÈÐ. – 1951. – Ñ. 12. 4. Ïðèêàç Ìèíçäðàâñîöðàçâèòèÿ Ðîññèè îò 24.04.2008 ã. ¹ 194í «Îá óòâåðæäåíèè ìåäè-öèíñêèõ êðèòåðèåâ îïðåäåëåíèÿ ñòåïåíè òÿæå-ñòè âðåäà, ïðè÷èíåííîãî çäîðîâüþ ÷åëîâåêà». 5. Óêàç Ïðåçèäåíòà Ðîññèéñêîé Ôåäåðà-öèè îò 5.02.2010 ã. ¹ 146 «Î Âîåííîé äîêò-ðèíå Ðîññèéñêîé Ôåäåðàöèè» // Ðîññèéñêàÿ ãàçåòà. – 10.02.2010. – ¹ 146. – Ñ. 6.6. Emergency war surgery [Ýëåêòðîííûé ðåñóðñ]. – Ðåæèì äîñòóïà: http://www. emergency_war_surgery 2004/emergency_war_ surgery.html
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ÎÐÃÀÍÈÇÀÖÈß ÌÅÄÈÖÈÍÑÊÎÃÎ ÎÁÅÑÏÅ×ÅÍÈß ÂÎÎÐÓÆÅÍÍÛÕ ÑÈË © Ì.Ñ.ÅËÎÅÂ, Â.Ì.ÊËÈÏÀÊ, 2013 ÓÄÊ 614.2:355Îïûò, ïðîáëåìû è ïåðñïåêòèâû ðàçâèòèÿ
ìíîãîïðîôèëüíîãî àìáóëàòîðíî-ïîëèêëèíè÷åñêîãî
ó÷ðåæäåíèÿ â òåððèòîðèàëüíîé ñèñòåìå
ìåäèöèíñêîãî îáåñïå÷åíèÿ â Ìîñêîâñêîì ðåãèîíå
ÅËÎÅ Ì.Ñ., çàñëóæåííûé âðà÷ ÐÔ, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû â îòñòàâêå ([email protected]) ÊËÈÏÀÊ Â.Ì., çàñëóæåííûé âðà÷ ÐÔ, ïðîôåññîð, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû â îòñòàâêå Ôèëèàë ¹ 5 3-ãî Öåíòðàëüíîãî âîåííîãî êëèíè÷åñêîãî ãîñïèòàëÿ èì. À.À.Âèøíåâñêîãî, ÌîñêâàEloev M.S., Kli pak V.M. – Experience, problems and prospects of development of multifield outpatient
department in area system of medical supply of Moscow region. The article concerns the problems
of development of ambulatory medical aid in Moscow and the regions of Moscow. The general conclusion is revealed from the broad modern experience of multi-field medical center. Moreover, the article demonstrates the performance of improvement in accordance with reorganization of public and military health service. K e y w o r d s: ambulatory medical aid, polyclinic, health center, reorganization.
Â
ïîñëåäíèå ãîäû ðàçâèòèþ è íèçàöèè çäðàâîîõðàíåíèÿ óäåëÿåòñÿ ïîñòîÿííîå âíèìàíèå ñî ñòîðîíû êàê ãî-ñóäàðñòâà, òàê è ìåäèöèíñêîé îáùåñòâåí-íîñòè. Ïðèíÿòû âàæíûå çàêîíîäàòåëüíûå àêòû, âûäåëÿþòñÿ çíà÷èòåëüíûå ôèíàí-ñîâûå ñðåäñòâà, îðãàíèçóþòñÿ îáñóæäå-íèÿ ïóòåé ïîâûøåîáñóæäå-íèÿ ýôôåêòèâíîñòè îòðàñëè [1, 2, 4, 5, 12, 13, 18]. Ïîäòâåðæäåíî, ÷òî ïî-ïðåæíåìó â öåëÿõ ñíèæåíèÿ çàòðàòíîñòè çäðàâî-îõðàíåíèÿ, ïîâûøåíèÿ åãî äîñòóïíîñòè è ýôôåêòèâíîñòè îäíèì èç ãëàâíûõ ïðè-îðèòåòîâ ðàçâèòèÿ ÿâëÿåòñÿ ñîâåðøåí-ñòâîâàíèå äåÿòåëüíîñòè àìáóëàòîðíî-ïî-ëèêëèíè÷åñêèõ ó÷ðåæäåíèé, äàëüíåéøåå óâåëè÷åíèå èõ ëå÷åáíî-äèàãíîñòè÷åñêèõ è ïðîôèëàêòè÷åñêèõ âîçìîæíîñòåé, îðãà-íèçàöèÿ äíåâíûõ ñòàöèîíàðîâ, âíåäðåíèå ñòàöèîíàðîçàìåùàþùèõ òåõíîëîãèé, ñîâåðøåíñòâîâàíèå èíôîðìàöèîííûõ ñèñòåì [1, 2, 4, 12, 13, 15]. Íà ýòè âîïðîñû îáðàòèë îñîáîå âíè-ìàíèå ïðîøåäøèé â îêòÿáðå 2012 ã. Ïåð-âûé íàöèîíàëüíûé ñúåçä âðà÷åé Ðîññèé-ñêîé Ôåäåðàöèè, îïðåäåëèâøèé ãëàâíûå íàïðàâëåíèÿ ðàçâèòèÿ îòå÷åñòâåííîãî çäðàâîîõðàíåíèÿ. Íàöèîíàëüíûé ïðîåêò «Çäîðîâüå», ïðåäóñìàòðèâàþùèé óñèëåíèå ïåðâè÷íî-ãî, â ò. ÷. àìáóëàòîðíî-ïîëèêëèíè÷åñêîïåðâè÷íî-ãî, çâåíà, – ïî ñóòè äîïîëíèòåëüíîå ïîäòâåð-æäåíèå âåäóùåé òåíäåíöèè ðàçâèòèÿ çäðàâîîõðàíåíèÿ, òðåáóþùåé ïåðåíîñà àêöåíòà â ñîâåðøåíñòâîâàíèè ëå÷åáíî-ïðîôèëàêòè÷åñêîé ïîìîùè íàñåëåíèþ ñî ñòàöèîíàðíîãî íà àìáóëàòîðíî-ïîëè-êëèíè÷åñêèé ýòàï. Îñíîâîïîëàãàþùèì îðãàíèçàöèîííûì ìåõàíèçìîì ðåøåíèÿ ýòîé çàäà÷è ÿâëÿåòñÿ îðãàíèçàöèîííî-ïðàâîâàÿ è ôèíàíñîâàÿ ñàìîñòîÿòåëüíîñòü àìáóëàòîðíî-ïîëèêëèíè÷åñêèõ ó÷ðåæäåíèé. Ïîëèêëèíèêè è ñòàöèîíàðû – ýòî ïðèíöèïèàëüíî ðàçíûå ïî çàäà÷àì è òåõíîëîãèè ðàáîòû ó÷ðåæäåíèÿ. Ê òîìó æå ïîëèêëèíèêè ÿâëÿþòñÿ íàèáîëåå ìàñ-ñîâûìè è äîñòóïíûìè äëÿ ïàöèåíòîâ. Èìåííî â íèõ íà÷èíàþò è çàêàí÷èâàþò ëå÷åíèå îêîëî 80% âñåõ îáðàòèâøèõñÿ çà ìåäèöèíñêîé ïîìîùüþ [1, 4, 10].  ñâÿçè ñ ýòèì ñëåäóåò ïîä÷åðêíóòü, ÷òî ïîäîáíîå ðåàëèçóåìîìó â ïîñëåäíèå ãîäû îáúåäèíåíèå ïîëèêëèíèê è ñòàöè-îíàðîâ óæå áûëî â èñòîðèè îòå÷åñòâåí-íîãî çäðàâîîõðàíåíèÿ. Îïûò òàêîé ðå-îðãàíèçàöèè èçâåñòåí: îí ñïðàâåäëèâî è îäíîçíà÷íî îöåíåí êàê íåãàòèâíûé, òîðìîçÿùèé ðàçâèòèå ïîëèêëèíèê êàê ñàìûõ ìàññîâûõ ëå÷åáíî-ïðîôèëàêòè-÷åñêèõ ó÷ðåæäåíèé, îáåñïå÷èâàþùèõ ïðîôèëàêòè÷åñêóþ íàïðàâëåííîñòü è äîñòóïíîñòü ìåäèöèíñêîé ïîìîùè.17
«Âîåííî-ìåäèöèíñêèé æóðíàë», 1’2013 ÎÐÃÀÍÈÇÀÖÈß ÌÅÄÈÖÈÍÑÊÎÃÎ ÎÁÅÑÏÅ×ÅÍÈß ÂÎÎÐÓÆÅÍÍÛÕ ÑÈË – äîáèòüñÿ âûñîêîãî êà÷åñòâà îêà-çàíèÿ àìáóëàòîðíî-ïîëèêëèíè÷åñêîé ìåäèöèíñêîé ïîìîùè; – îïòèìèçèðîâàòü è îáåñïå÷èòü êà-÷åñòâåííóþ ðàáîòó ëå÷åáíî-äèàãíîñòè-÷åñêèõ îòäåëåíèé è êàáèíåòîâ; – ðàñøèðèòü îáúåì ñïåöèàëèçèðî-âàííîé ìåäèöèíñêîé ïîìîùè â ËÄÖ; – ïðîâåñòè èíôîðìàòèçàöèþ ëå÷åá-íî-äèàãíîñòè÷åñêîãî ïðîöåññà; – ïîñòðîèòü è ââåñòè â ðàáîòó ëàáî-ðàòîðíûé êîðïóñ, îñíàñòèòü íåîáõîäè-ìûì ñîâðåìåííûì îáîðóäîâàíèåì, ïîä-íÿòü óðîâåíü ëàáîðàòîðíîé äèàãíîñòèêè; – ââåñòè â ðàáîòó õèðóðãè÷åñêèé ñòà-öèîíàð êðàòêîñðî÷íîãî ïðåáûâàíèÿ ñ âîçìîæíîñòüþ âûïîëíåíèÿ îïåðàòèâíûõ âìåøàòåëüñòâ ðàñøèðåííîãî îáúåìà, ñ êðóãëîñóòî÷íûì íàáëþäåíèåì è ïèòàíè-åì áîëüíûõ; – ñîâåðøåíñòâîâàòü ðàáîòó îñíîâíûõ äèàãíîñòè÷åñêèõ ïîäðàçäåëåíèé öåíòðà (îòäåëåíèÿ ýëåêòðîôèçèîëîãè÷åñêèõ èñ-ñëåäîâàíèé ñåðäöà, óëüòðàçâóêîâûõ èññëå-äîâàíèé ñåðäå÷íî-ñîñóäèñòîé ñèñòåìû, ìàãíèòíî-ðåçîíàíñíîé òîìîãðàôèè, ýíäîñêîïèè è äð.). Îñíîâíûìè íàïðàâëåíèÿìè äàëüíåéøåãî ðàçâèòèÿ ËÄÖ ÿâëÿþòñÿ: – ñîâåðøåíñòâîâàíèå îðãàíèçàöè-îííî-øòàòíîé ñòðóêòóðû ñ ó÷åòîì ïðîâî-äèìûõ ðåôîðì è ñóùåñòâóþùèõ óðîâíåé îêàçàíèÿ ìåäèöèíñêîé ïîìîùè; – âíåäðåíèå íîâûõ ôîðì îöåíêè ðåçóëüòàòîâ äåÿòåëüíîñòè ïîäðàçäåëåíèé äëÿ ôîðìèðîâàíèÿ â äàëüíåéøåì ãîñó-äàðñòâåííîãî çàäàíèÿ ó÷ðåæäåíèÿ â ñî-îòâåòñòâèè ñ Ïîñòàíîâëåíèåì Ïðàâè-òåëüñòâà ÐÔ îò 2.09.2010 ã. ¹ 671; – îïòèìèçàöèÿ è ðàçâèòèå ðàçëè÷-íûõ ôîðì äèñïàíñåðèçàöèè âîåííîñëó-æàùèõ, îôèöåðîâ çàïàñà è â îòñòàâêå, ìåòîäîâ ïåðâè÷íîé è âòîðè÷íîé ïðîôè-ëàêòèêè; – îáåñïå÷åíèå âûñîêîãî êà÷åñòâà è äîñòóïíîñòè îêàçàíèÿ ìåäèöèíñêîé ïî-ìîùè ñ ðåàëèçàöèåé ïðèíöèïîâ óïðàâ-ëåíèÿ è êîíòðîëÿ; – ñîâåðøåíñòâîâàíèå ëàáîðàòîðíîé äèàãíîñòèêè ïóòåì âíåäðåíèÿ ñîâðåìåí-íûõ íàóêîåìêèõ ìåòîäèê è èññëåäîâàíèé; – ñîâåðøåíñòâîâàíèå ðàáîòû â ñèñ-òåìå ÎÌÑ, ÄÌÑ ñ öåëüþ ñîõðàíåíèÿ ñòà-òóñà ËÄÖ íà ðûíêå ïëàòíûõ óñëóã; – ðàñøèðåíèå è îïòèìèçàöèÿ ñòî-ìàòîëîãè÷åñêîé ïîìîùè ïðèêðåïëåííûì êîíòèíåíòàì; – ïðîäîëæåíèå ðàáîò ïî âíåäðåíèþ èíôîðìàöèîííîé ìåäèöèíñêîé ñèñòåìû ñ âêëþ÷åíèåì âñåõ ïîëèêëèíèê è ñòðóê-òóðíûõ ïîäðàçäåëåíèé ñ öåëüþ ïîâûøå-íèÿ êà÷åñòâà è äîñòóïíîñòè îêàçàïîâûøå-íèÿ ìåäèöèíñêîé ïîìîùè ïðèêðåïëåííûì êîíòèíãåíòàì.  öåëÿõ äàëüíåéøåãî ñîâåðøåíñòâî-âàíèÿ àìáóëàòîðíî-ïîëèêëèíè÷åñêîé ïîìîùè â òåððèòîðèàëüíîé ñèñòåìå ìå-äèöèíñêîãî îáåñïå÷åíèÿ Ìîñêîâñêîãî ðåãèîíà è ó÷èòûâàÿ ñîâðåìåííûå òåí-äåíöèè ðåôîðìèðîâàíèÿ ìåäèöèíñêîé ñëóæáû ÂÑ ÐÔ, ïðåäñòàâëÿåòñÿ íåîáõî-äèìûì ñîçäàíèå íà áàçå ËÄÖ (íûíåø-íåãî ôèëèàëà ¹ 5 3-ãî Öåíòðàëüíîãî âîåííîãî êëèíè÷åñêîãî ãîñïèòàëÿ èìåíè À.À.Âèøíåâñêîãî) ñàìîñòîÿòåëüíîãî â îðãàíèçàöèîííî-ïðàâîâîì è ôèíàíñîâîì îòíîøåíèè ôåäåðàëüíîãî áþäæåòíîãî ó÷ðåæäåíèÿ. Ýòî ïîçâîëèò, èñïîëüçóÿ îïûò ïðåäøåñòâóþùèõ ëåò, çíà÷èòåëüíî óêðåïèòü àìáóëàòîðíî-ïîëèêëèíè÷åñêîå çâåíî ìåäèöèíñêîé ñëóæáû Ìîñêîâñêî-ãî ðåãèîíà, ÷òî ÿâèòñÿ ïðàêòè÷åñêîé ðå-àëèçàöèåé òðåáîâàíèé êàê ïåðå÷èñëåí-íûõ âûøå äîêóìåíòîâ, òàê è âûâîäîâ ó÷åíûõ è ïðàêòèêîâ î ïóòÿõ ðåôîðìè-ðîâàíèÿ îòå÷åñòâåííîãî çäðàâîîõðà-íåíèè è ìåäèöèíñêîé ñëóæáû Âîîðó-æåííûõ ñèë.Ëèòåðàòóðà
1. Áûêîâ È.Þ. Àêòóàëüíûå âîïðîñû ñî-âåðøåíñòâîâàíèÿ ðàáîòû àìáóëàòîðíî-ïîëè-êëèíè÷åñêèõ ó÷ðåæäåíèé Âîîðóæåííûõ ñèë Ðîññèéñêîé Ôåäåðàöèè // Âîåí.-ìåä. æóðí. – 2006. – Ò. 327, ¹ 11. – Ñ. 4–6. 2. Ãîëèêîâà Ò. Îñíîâíûå íàïðàâëåíèÿ ðàçâèòèÿ çäðàâîîõðàíåíèÿ îðèåíòèðîâàíû íà ïîâûøåíèå êà÷åñòâà è ýôôåêòèâíîñòè ìåäè-öèíñêîãî îáñëóæèâàíèÿ // Âîïðîñû ýêñïåð-òèçû è êà÷åñòâà ìåäèöèíñêîãî îáñëóæèâàíèÿ. – 2011. – ¹ 7. – Ñ. 3–12. 3. Ãðîçäîâà Ò.Þ. Î ïðèîðèòåòíûõ íàïðàâ-ëåíèÿõ ïðàêòè÷åñêîãî âíåäðåíèÿ ðåãèîíàëü-íûõ ïðîãðàìì èíôîðìàòèçàöèè â ñóáúåêòå Ôåäåðàöèè // Ãëàââðà÷. – 2012. – ¹ 3. – Ñ. 28–32. 4. Ãóëÿåâ Â.À., Êàðòàøîâ Â.Ò. Ñòàöèîíà-ðîçàìåùàþùèå òåõíîëîãèè – îñíîâà ðåôîð-2ÎÐÃÀÍÈÇÀÖÈß ÌÅÄÈÖÈÍÑÊÎÃÎ ÎÁÅÑÏÅ×ÅÍÈß ÂÎÎÐÓÆÅÍÍÛÕ ÑÈË ìèðîâàíèÿ ëå÷åáíî-äèàãíîñòè÷åñêîé áàçû âîåííîãî çäðàâîîõðàíåíèÿ // Âîåí.-ìåä. æóðí. – 2001. – Ò. 322, ¹ 2. – Ñ. 4–14. 5. Äóäèí Ì.Í. Âîïðîñû èííîâàöèîííîãî ðåôîðìèðîâàíèÿ îòå÷åñòâåííîãî çäðàâîîõðà-íåíèÿ: ðàçâèòèå îáùåé âðà÷åáíîé ïðàêòèêè â Ðîññèè // Ãëàââðà÷. – 2012. – ¹ 11. – Ñ. 14–17. 6. Åëîåâ Ì.Ñ., Æóðàâë¸â Ñ.Â., Áóëàòîâ Ì.Ð. Îïûò ðàáîòû õèðóðãè÷åñêîãî ñòàöèîíàðà êðàòêîñðî÷íîãî ïðåáûâàíèÿ ìíîãîïðîôèëü-íîãî àìáóëàòîðíî-ïîëèêëèíè÷åñêîãî ó÷ðåæ-äåíèÿ // Âîåí.-ìåä. æóðí. – 2012. – Ò. 333, ¹ 4. – Ñ. 18–23. 7. Êàëìûêîâ À.À. Ìåäèöèíñêîå îáåñïå÷å-íèå Âîîðóæåííûõ ñèë Ðîññèè: èòîãè äåÿòåëü-íîñòè è îñíîâíûå çàäà÷è íà 2012 ãîä // Âîåí.-ìåä. æóðí. – 2012. – Ò. 333, ¹ 1. – Ñ. 4–11. 8. Êàðòàøîâ Â.Ò. Ìåòîäè÷åñêèå è ïðàê-òè÷åñêèå ïîäõîäû ê óïðàâëåíèþ êà÷åñòâîì ìåäèöèíñêîé ïîìîùè â êðóïíîì âîåííîì ïîëèêëèíè÷åñêîì ó÷ðåæäåíèè // Âîåí.-ìåä. æóðí. – 2004. – Ò. 325, ¹ 4. – Ñ. 15–23. 9. Êëèïàê Â.Ì., Ðîìàíîâñêèé Â.Ã., Ùêðóä-íåâ Ë.Ä. è äð. Îñîáåííîñòè îêàçàíèÿ ìåäèöèí-ñêîé ïîìîùè â óñëîâèÿõ õèðóðãè÷åñêîãî ñòà-öèîíàðà êðàòêîñðî÷íîãî ïðåáûâàíèÿ // Ìà-òåðèàëû Âñåðîñ. íàó÷.-ïðàêò. êîíô. «Íåîòëîæ-íàÿ ìåäèöèíñêàÿ ïîìîùü (ñîñòîÿíèå, ïðîáëå-ìû, ïåðñïåêòèâû ðàçâèòèÿ). – ÔÁÓ «Ãëàâíûé âîåííûé êëèíè÷åñêèé ãîñïèòàëü èìåíè Í.Í.Áóðäåíêî», 9 äåêàáðÿ 2011 ã. – Ñ. 46. 10. Ìàêñèìîâ È.Á., Ñòîëÿð Â.Ï. Î ïðîáëå-ìàõ è ïåðñïåêòèâàõ ñîâåðøåíñòâîâàíèÿ óï-ðàâëåíèÿ ñîâðåìåííûìè ãîñïèòàëüíûìè îáúåäèíåíèÿìè // Âîåí.-ìåä. æóðí. – 2011. – Ò. 332, ¹ 10. – Ñ. 4–8. 11. Îá îñíîâàõ îõðàíû çäîðîâüÿ ãðàæäàí â Ðîññèéñêîé Ôåäåðàöèè. Ôåäåðàëüíûé çàêîí Ðîñ-ñèéñêîé Ôåäåðàöèè îò 21.11. 2011 ã. ¹ ÔÇ-323. 12. Ïàïûðèí À. Ñúåçä íàäåæäû // Ìåä. ãà-çåòà. – 10.10.2012. – ¹ 75. 13. Ïåðâûé ñúåçä âðà÷åé. Ïðîôåññèîíà-ëèçì, ÷óâñòâî îòâåòñòâåííîñòè è ðàâíîïðàâèå // Ìåä. ãàçåòà. – 5.10.2012. – ¹ 74. 14. Ïîïîâ À.Ï., Ëàíîâåíêî Þ.Ï., Ïàâëîâà È.Â. Íåêîòîðûå àñïåêòû àìáóëàòîðíî-ïîëèêëèíè-÷åñêîé ðàáîòû â ñîâðåìåííûõ óñëîâèÿõ // Âîåí.-ìåä. æóðí. – 2011. – Ò. 332, ¹ 11. – Ñ. 14–19. 15. Ñêâèðñêàÿ Ã.Ï., Èëü÷åíêî È.Í., Ñûð-öîâà Ë.Å., Àáðîñèìîâà Þ.Å. Ñòðóêòóðíî-îðãà-íèçàöèîííàÿ ìîäåëü ïðîôèëàêòè÷åñêîé äåÿòåëüíîñòè àìáóëàòîðíî-ïîëèêëèíè÷åñêèõ ó÷ðåæäåíèé è ñïåöèàëèñòîâ. Ïðàêòè÷åñêèå ðåêîìåíäàöèè // Ãëàââðà÷. Ïðèëîæåíèå ê æóðíàëó. – 2012. – ¹ 3. – Ñ. 3–67. 16. Óëóìáåêîâà Ã.Ý. Âûçîâû ñèñòåìû çäðàâîîõðàíåíèÿ ÐÔ: ïóòè ðåøåíèÿ // Ãëàâ-âðà÷. – 2012. – ¹ 5. – Ñ. 13–22. 17. ×èæ È.Ì. Íàïðàâëåíèÿ ñîâåðøåíñòâî-âàíèÿ äåÿòåëüíîñòè ìåäèöèíñêîé ñëóæáû Âîîðóæåííûõ ñèë // Âîåí.-ìåä. æóðí. – 2003. – Ò. 324, ¹ 6. – Ñ. 4–12. 18. Ùåãëîâ Ê. «Ïëàíêó îæèäàíèé» îáåùàþò ïîâûñèòü // Ìåä. ãàçåòà. – 23.11.2012. – ¹ 88. Âåñü ëè÷íûé ñîñòàâ, ïðèáûâøèé ïî ïëàíîâîé çàìåíå èç Ðîññèéñêîé Ôåäåðàöèè äëÿ ïðîõîæäåíèÿ ñëóæáû â ïîäðàçäåëåíèÿõ âîåííîé áàçû, äèñëîöèðîâàííîé íà òåð-ðèòîðèè Ðåñïóáëèêè Àðìåíèÿ, ïðîøåë âàêöèíàöèþ îò ãðèïïà, ÎÐÂÈ, ãåïàòèòà è äðó-ãèõ çàáîëåâàíèé. Âñå âîåííîñëóæàùèå ïåðåä îòïðàâêîé ïðîøëè ôëþîðîãðàôèþ.  öåëÿõ ïîääåðæàíèÿ çäîðîâüÿ âîåííîñëóæàùèõ â çèìíèé ïåðèîä ìåäèöèíñêîé ñëóæáîé ïðîâîäèòñÿ êîìïëåêñ ìåðîïðèÿòèé ïî ïðîôèëàêòèêå ñåçîííûõ çàáîëåâàíèé. Ââåäåí ðåæèì îáñåðâàöèè, ïîäãîòîâëåíû ê ðàçâåðòûâàíèþ íåøòàòíûå èçîëÿòîðû, îïðåäåëåí ïîðÿäîê ñêâîçíîãî ïðîâåòðèâàíèÿ æèëûõ è ñëóæåáíûõ ïîìåùåíèé.  ïîäðàçäåëåíèÿõ óñòàíîâëåíû èîíèçàòîðû äëÿ î÷èñòêè âîçäóõà. Òàêæå â åæåäíåâíûé ðàöèîí ïèòàíèÿ ñîëäàò è ñåðæàíòîâ âêëþ÷åíû ôðóêòû, âèòàìèííûå ñàëàòû è ïëîäîâî-ÿãîäíûå ñîêè. Äëÿ íåäîïóùåíèÿ ïåðåîõëàæäåíèé íà âîåííûõ ïîëèãîíàõ Êàìõóä è Àëàãÿç ñî-çäàíû ïàëàòî÷íûå ïóíêòû îáîãðåâà, â êîòîðûõ âîåííîñëóæàùèå íàõîäÿòñÿ ïîñëå êàæäîãî ó÷åáíîãî ÷àñà çàíÿòèé, à ïðè ïðîâåäåíèè çàíÿòèé îãðàíè÷åíî âðåìÿ íà-õîæäåíèÿ íà îòêðûòîì âîçäóõå. Íåñåíèå ñëóæáû â êàðàóëå îñóùåñòâëÿåòñÿ òîëüêî â âàëåíêàõ è òåïëûõ òóëóïàõ, âàòíûõ øòàíàõ è òåïëûõ ðóêàâèöàõ, êîòîðûìè ñîåäèíåíèå îáåñïå÷åíî ïîëíîñòüþ.  ñîåäèíåíèè ñîçäàí íåîáõîäèìûé çàïàñ àíòèáàêòåðèàëüíûõ è ïðîòèâîâèðóñ-íûõ ïðåïàðàòîâ íîâîãî ïîêîëåíèÿ.  ýòîì ãîäó óðîâåíü ïðîñòóäíîé çàáîëåâàåìîñòè íå ïðåâûøàåò ïðîøëîãîäíèå ïîêàçàòåëè. Ïðåññ-ñëóæáà Þæíîãî âîåííîãî îêðóãà, 17 äåêàáðÿ 2012 ã. http://stat.function.mil.ru/news_page/country/more.htm?id=11534613@egNews
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«Âîåííî-ìåäèöèíñêèé æóðíàë», 1’2013ÌÅÄÈÖÈÍÀ
ÝÊÑÒÐÅÌÀËÜÍÛÕ ÑÈÒÓÀÖÈÉ
© ÊÎËËÅÊÒÈ ÀÂÒÎÐÎÂ, 2013 ÓÄÊ 616-001.45-07:616.155.1-074Ñòðóêòóðà öèòîïëàçìàòè÷åñêèõ ìåìáðàí
è õèìè÷åñêèé ñîñòàâ ýðèòðîöèòîâ â ðàííèé ïåðèîä
ðàíåâûõ ïîâðåæäåíèé ïî äàííûì ñêàíèðóþùåé
çîíäîâîé ìèêðîñêîïèè
ÁÅËÎÓÑÎÂÀ Î.Ä. ([email protected])1 ÃÀÉÄÀØ À.À., ïðîôåññîð1 ÒÎËÌÀר È.À., ïðîôåññîð, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû çàïàñà1 ÈÂ×ÅÍÊÎ Å.Â., äîöåíò, ïîäïîëêîâíèê ìåäèöèíñêîé ñëóæáû1 ÃÎËÓÁÎÊ À.Î., ïðîôåññîð, äîêòîð ôèçèêî-ìàòåìàòè÷åñêèõ íàóê ([email protected])2 ËÅÂÈ×Å Â.Â., êàíäèäàò ôèçèêî-ìàòåìàòè÷åñêèõ íàóê2 ÌÓÕÈÍ È.Ñ.2 ÆÓÊΠÌ.Â.2 ÁÅËÎÓÑΠÈ.Ñ., êàíäèäàò ìåäèöèíñêèõ íàóê ([email protected])3 ÒÊÀ×ÓÊ È.Â., êàíäèäàò ìåäèöèíñêèõ íàóê ([email protected])4 1Âîåííî-ìåäèöèíñêàÿ àêàäåìèÿ èì. Ñ.Ì.Êèðîâà, Ñàíêò-Ïåòåðáóðã; 2Ñàíêò-Ïåòåðáóðãñêèé íàöèîíàëüíûé èññëåäîâàòåëüñêèé óíèâåðñèòåò èíôîðìàöèîííûõ òåõíîëîãèé, ìåõàíèêè è îïòèêè; 3Öåíòðàëüíàÿ áîëüíèöà Ëîìîíîñîâñêîãî ðàéîíà, ã. Ëîìîíîñîâ, Ëåíèíãðàäñêàÿ îáëàñòü; 4Ìíîãîïðîôèëüíàÿ êëèíèêà èì. Í.È.Ïèðîãîâà, Ñàíêò-ÏåòåðáóðãBelousova O.D., Gaidash A.A., Tolmachyov I.A., Ivchenko E.V., Golubok A.O., Levichev V.V., Mukhin I.S., Gykov M.V., Belousov I.S., Tkachuk I.V. – Structure of cytosolic membrane and chemical composition of red blood cell during the early period of wound damage according to scanning probe microscopy. With the help of scanning electronic and atomic force microscopy structure of red blood cell membranes of the system blood-groove and microcirculatory channels is studied. It is established, that in early stages of skin wounds in a peri pheral blood circulation appear compressed red blood cells, losing water. As a result the basic mechanism of destruction of red blood cell membranes are interlayered shifts and stratification. In red blood cells of microvasculature, on the contrary, red blood cells in state of vacuolar degeneration are indentified. It creates preconditions for hydration and bullous deformations of membranes. Porous structures of membranes of both types erythrocytes are exposed to expansion.
K e y w o r d s: skin wound, erythrocytes, remoteness of damage, scanning electronic and atomic force microscopy, hydration, stratification, erosion, expansion of pores of cytoplasmatic membranes.
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îðôîëîãè÷åñêàÿ äèàãíîñòèêà íèõ (10–30 ìèí îò íà÷àëà âîçäåé-ñòâèÿ) ïðèçíàêîâ ðàíåâûõ ïîâðåæäåíèé, ñåìèîòèêà êîòîðûõ îïðåäåëÿåòñÿ õàðàê-òåðîì ðåàãèðîâàíèÿ òîíêèõ ñòðóêòóð êëåòîê è òêàíåé, âûçûâàåò çíà÷èòåëüíûå çàòðóäíåíèÿ [3, 4]. Èçâåñòíî, ÷òî â ðàííèé ïåðèîä òðàâìàòè÷åñêîãî ñòðåññà äîñòà-òî÷íî áûñòðî ðàçâèâàåòñÿ êëåòî÷íûé è òêàíåâîé îòåê. Ìåõàíèçì îòåêà îñòàåòñÿ íå â ïîëíîé ìåðå èçó÷åííûì. Ðàííèå ýôôåêòû, ïî-âèäèìîìó, îáóñëîâëåíû áûñòðîòåêóùèìè èçìåíåíèÿìè â ñòðóê-òóðíî-ôóíêöèîíàëüíîé îðãàíèçàöèè ïðåæäå âñåãî êëåòî÷íûõ ìåìáðàí. Ýðèòðî-öèòàðíûå ìåìáðàíû, íàïðèìåð, ïî÷òè ìãíîâåííî óâåëè÷èâàþò æåñòêîñòü â îòâåò íà ýêñòðåìàëüíîå âîçäåéñòâèå [2]. Âûñîêàÿ ñêîðîñòü ðàçâèòèÿ ïîäîáíûõ ïðîöåññîâ äåëàåò íåîáõîäèìûì ïðèìå-íåíèå ïðåöèçèîííûõ ìåòîäîâ èññëåäî-âàíèÿ, ïîçâîëÿþùèõ âèçóàëèçèðîâàòü ìèêðî- è íàíîñòðóêòóðû ìåìáðàííûõ ïîâåðõíîñòåé êëåòîê. Ñêàíèðóþùàÿ çîí-äîâàÿ ìèêðîñêîïèÿ îáëàäàåò òðåáóåìîé ðàçðåøàþùåé ñïîñîáíîñòüþ è ïîçâîëÿ-åò èçó÷àòü îáðàçöû ñ ìèíèìàëüíûì ïðî-áîðàçðóøåíèåì [1], à èñïîëüçóÿ ðåíòãåí-ýíåðãîäèñïåðñèîííûé àíàëèç (EDAX), ìîæ-íî îïðåäåëèòü ñîäåðæàíèå õèìè÷åñêèõ ýëåìåíòîâ â ÷åòêî èäåíòèôèöèðîâàííûõ ñòðóêòóðàõ [5].ÌÅÄÈÖÈÍÀ ÝÊÑÒÐÅÌÀËÜÍÛÕ ÑÈÒÓÀÖÈÉ òî êàñïàçíåçàâèñèìûé, ò. ê. ñòðóêòóðíûõ ïðåäïîñûëîê äëÿ ñèíòåçà êàñïàç â ýðèò-ðîöèòàõ íåò [7]. Îäíàêî ôóíäàìåíòàëü-íûì ìåõàíèçìîì äåñòðóêöèè òêàíåâûõ ýðèòðîöèòîâ, ïî-âèäèìîìó, ÿâëÿåòñÿ ãèä-ðàòàöèÿ. Èçâåñòíî, ÷òî ïðè èçáûòêå âîäû â ìàêðîìîëåêóëÿðíûõ ñòðóêòóðàõ âîç-íèêàþò î÷àãè ñòðóêòóðíîãî íàïðÿæåíèÿ ïðåèìóùåñòâåííî â ó÷àñòêàõ íàèáîëü-øåé ïëîùàäè êîíòàêòà âîäû ñ ðàñòâî-ðåííûìè ìîëåêóëàìè.  ðåçóëüòàòå ïî-ÿâëÿþòñÿ ìîçàè÷íûå òî÷êè íàêîïëåíèÿ æèäêîé âîäû. Òàê, ïî íàøåìó ìíåíèþ, ôîðìèðóþò-ñÿ ñòðóêòóðíûå ïðåäïîñûëêè äëÿ îáðà-çîâàíèÿ ìåìáðàííûõ ïóçûðåé. Èìåííî òàêîãî ðîäà áóëëåçíîå ïîâðåæäåíèå öè-òîïëàçìàòè÷åñêèõ ìåìáðàí âûÿâëÿåòñÿ â òêàíåâûõ ýðèòðîöèòàõ óæå íà ðàííèõ ñòàäèÿõ ðàíåâîãî ñòðåññà. Ìîðôîëîãè÷åñ-êè ýòî äîñòàòî÷íî õàðàêòåðíûé ôåíî-ìåí â âèäå âñïó÷èâàíèÿ ïîâåðõíîñòíûõ ñëîåâ ñòåíêè ýðèòðîöèòîâ ñ îáðàçîâàíè-åì ìèêðîâçäóòèé è ïóçûðåé. Ïîä âçäóòè-ÿìè ðàñïîëàãàþòñÿ ýðîçèè, à ïóçûðè çà-ïîëíåíû ëèïêîé æèäêîñòüþ, êîòîðàÿ ïðè âûòåêàíèè ïðèêëåèâàåò ê ïîâåðõíîñòè ýðèòðîöèòîâ ÷àñòèöû äåòðèòà è îáðûâêè êîëëàãåíîâûõ íèòåé. Çàêëþ÷åíèå Ïðèìåíåíèå ñêàíèðóþùåé çîíäîâîé ìèêðîñêîïèè ïîçâîëÿåò îïðåäåëèòü ïðåä-ìåòíóþ áàçó äèàãíîñòè÷åñêèõ ïðèçíàêîâ ïðè ñóäåáíî-ìåäèöèíñêîé îöåíêå íà÷àëü-íûõ ïðîÿâëåíèé ðåàêöèè îðãàíèçìà íà ïîâðåæäåíèå. Ïî îòíîøåíèþ ê ñèñòåì-íûì ýðèòðîöèòàì íàèáîëåå èíôîðìàòèâ-íûì ÿâëÿåòñÿ îáíàðóæåíèå êëåòîê, íàõî-äÿùèõñÿ â ñîñòîÿíèè ïèêíîçà.  öèòî-ïëàçìàòè÷åñêîé ìåìáðàíå òàêèõ ýðèòðî-öèòîâ ïðèñóòñòâóþò ýðîçèè è î÷àãè ðàñ-ñëîåíèÿ. Ïðè èçó÷åíèè ýðèòðîöèòîâ èç òêàíåâûõ îòïå÷àòêîâ íàèáîëåå çíà÷èìûì ÿâëÿåòñÿ îáíàðóæåíèå êëåòîê, íàõîäÿùèõ-ñÿ â ñîñòîÿíèè îòåêà. Öèòîïëàçìàòè÷åñ-êàÿ ìåìáðàíà òàêèõ ýðèòðîöèòîâ ïîäâåð-ãàåòñÿ áóëëåçíî-ÿçâåííîé äåñòðóêöèè. Îáùèì è íåñïåöèôè÷åñêèì ïðèçíàêîì ïîâðåæäåíèé ÿâëÿåòñÿ øèðîêîïîðèñòàÿ òðàíñôîðìàöèÿ öèòîïëàçìàòè÷åñêèõ ìåìáðàí, õàðàêòåðíàÿ êàê äëÿ ñèñòåìíûõ, òàê è äëÿ òêàíåâûõ ýðèòðîöèòîâ. Ïîëó÷åííûå äàííûå ñâèäåòåëüñòâó-þò î òîì, ÷òî ìåòîäû ñêàíèðóþùåé çîí-äîâîé ìèêðîñêîïèè ïîçâîëÿþò ðàñøè-ðèòü íàáîð ïðèçíàêîâ, óòî÷íÿþùèõ ñó-äåáíî-ìåäèöèíñêóþ äèàãíîñòèêó äàâíî-ñòè ðàíåíèé.
Ëèòåðàòóðà
1. Áûêîâ È.Â. Ðàçâèòèå è àâòîìàòèçàöèÿ ìåòîäîâ èçìåðåíèÿ ðåëüåôà è ëîêàëüíûõ ñâîéñòâ áèîëîãè÷åñêèõ îáúåêòîâ â àòîìíî-ñèëîâîé ìèêðîñêîïèè: Àâòîðåô. äèñ. ... êàíä. ôèç.-ìàò. íàóê. – Ì., 2010. – 18 ñ. 2. Çàõàðîâ Ñ.Ä. Ýíòðîïèéíûé õàðàêòåð óïðóãîñòè æèâîé êëåòêè (ýðèòðîöèòà) // Êðàòêèå ñîîáùåíèÿ ïî ôèçèêå ÔÈÀÍ. – 1986. – ¹ 2. – Ñ. 3–5. 3. Ðóêîâîäñòâî ïî ñóäåáíîé ìåäèöèíå / Ïîä ðåä. Â.Â.Òîìèëèíà, Ã.À.Ïàøèíÿíà. – Ì.: Ìåäèöèíà, 2001. – 576 ñ. 4. Õàñàíÿíîâà Ñ.Â. Ñóäåáíî-ìåäèöèíñêîå îïðåäåëåíèå äàâíîñòè îáðàçîâàíèÿ ïðèæèç-íåííûõ êîæíûõ ðàí: Äèñ. ... êàíä. ìåä. íàóê. – Èæåâñê, 2002. – 200 ñ.5. EDAX. Advanced microanalysis solutions [Ýëåêòðîííûé ðåñóðñ]. Äîñòóï: http://www. edax.com, ñâîáîäíûé.
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«Âîåííî-ìåäèöèíñêèé æóðíàë», 1’2013ËÅ×ÅÁÍÎ-ÏÐÎÔÈËÀÊÒÈ×ÅÑÊÈÅ
ÂÎÏÐÎÑÛ
© ÊÎËËÅÊÒÈÂ ÀÂÒÎÐÎÂ, 2013 ÓÄÊ [616.419-008.6-02:616-001.28]-08Ñîâðåìåííîå ñîñòîÿíèå è ïåðñïåêòèâû
ñîâåðøåíñòâîâàíèÿ ñïåöèàëèçèðîâàííîé
ìåäèöèíñêîé ïîìîùè ïðè îñòðîì êîñòíîìîçãîâîì
ñèíäðîìå ðàäèàöèîííîé ýòèîëîãèè
ÕÀËÈÌÎÂ Þ.Ø., çàñëóæåííûé âðà÷ ÐÔ, ïðîôåññîð, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû ([email protected]) ÃÐÅÁÅÍÞÊ À.Í., ïðîôåññîð, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû ËÅÃÅÇÀ Â.È., çàñëóæåííûé äåÿòåëü íàóêè ÐÔ, ïðîôåññîð, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû â îòñòàâêå ÊÀÐÀÌÓËËÈÍ Ì.À., äîêòîð ìåäèöèíñêèõ íàóê, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû ÑÀËÓÕÎÂ Â.Â., êàíäèäàò ìåäèöèíñêèõ íàóê, ïîëêîâíèê ìåäèöèíñêîé ñëóæáû Âîåííî-ìåäèöèíñêàÿ àêàäåìèÿ èì. Ñ.Ì.Êèðîâà, Ñàíêò-ÏåòåðáóðãKhalimov Yu.Sh., Grebenyuk À.N., Legeza V.I., Karamullin M.A., Salukhov V.V. – Modern condition and prospects of improvement of the specialized medical aid of acute marrow failure of radiant etiology. It is shown, that tactics of treatment of acute marrow failure of radiant etiology is based, first of all, on measures of supporting, replaceable and stimulating therapy. The modern means, used for prophylactic and treatment of infectious complications, are resulted. Opportunities and restrictions of transfusion of donor thrombocytes and granulocytes, erythrocytes and chilled plasma are described. Therapeutic efficiency of transplantation of a bone marrow, cells of embryonic liver and stem cells of peri pheral or umbilical cord blood is analyzed. It is shown, that the greatest prospects in perfection of the specialized medical aid at acute radiation syndrome are connected to complex application of interleukin-1â, interleukin-3, granulocyte or granulocyte/macrophage colony stimulated factor, thrombopoietin and others cytokines.
K e y w o r d s: radiating injures, acute marrow failure of radiant etiology, specialized medical aid, treatment, transplantation, cytokines.
Í
àñòîÿùàÿ ñòàòüÿ ïðîäîëæàåò öèêë ïóáëèêàöèé, ïîñâÿùåííûõ ðàññìî-òðåíèþ îðãàíèçàöèîííûõ è êëèíè÷åñêèõ ïðîáëåì âîåííîé ðàäèîëîãèè.  ïðåäûäó-ùåé ñòàòüå [12] áûëè ïðåäñòàâëåíû ñóùå-ñòâóþùèå è ïåðñïåêòèâíûå ïîäõîäû ê îêà-çàíèþ ïîìîùè íà âîéñêîâûõ ýòàïàõ ìåäè-öèíñêîé ýâàêóàöèè ïðè âîçíèêíîâåíèè ìàññîâûõ ñàíèòàðíûõ ïîòåðü ïðè ðàäèàöè-îííûõ àâàðèÿõ (êàòàñòðîôàõ), à íàñòîÿùàÿ ïóáëèêàöèÿ ïîñâÿùåíà ñîâðåìåííîé òàê-òèêå ëå÷åíèÿ ïîðàæåííûõ ðàäèàöèîííîãî ïðîôèëÿ â ñïåöèàëèçèðîâàííîì òåðàïåâ-òè÷åñêîì ñòàöèîíàðå. Êàê ïîêàçûâàåò îïûò ëå÷åíèÿ ðàäèàöèîííûõ ïîðàæåíèé, èìåí-íî íà ýòàïå îêàçàíèÿ ñïåöèàëèçèðîâàíèìåí-íîé ìåäèöèíñêîé ïîìîùè âîçìîæíî ïðîâåäå-íèå ìåðîïðèÿòèé, ñïîñîáíûõ, áåç ïðåóâå-ëè÷åíèÿ, ñïàñòè æèçíü è çäîðîâüå ïîñòðà-äàâøèõ îò âîçäåéñòâèÿ èîíèçèðóþùèõ èç-ëó÷åíèé, îñîáåííî â âûñîêèõ äîçàõ. Èçâåñòíî, ÷òî ê îäíèì èç íàèáîëåå ãðîçíûõ ïîñëåäñòâèé âîçäåéñòâèÿ íà îðãà-íèçì èîíèçèðóþùèõ èçëó÷åíèé îòíîñèò-ñÿ ðàçâèòèå îñòðîé ëó÷åâîé áîëåçíè (ÎËÁ) – ïàòîëîãè÷åñêîãî ñîñòîÿíèÿ, õàðàêòåðè-çóþùåãîñÿ ñîâîêóïíîñòüþ ïîðàæåíèé ðàçëè÷íûõ îðãàíîâ è òêàíåé è íàðóøå-íèåì ïðîöåññîâ ôèçèîëîãè÷åñêîé ðåïà-ðàöèè [4, 8]. ÎËÁ ïðåäñòàâëÿåò ñîáîé ïî-ëèñèíäðîìíîå çàáîëåâàíèå, ïðè êîòîðîì â çàâèñèìîñòè îò ïîãëîùåííîé äîçû îá-ëó÷åíèÿ âåäóùóþ ðîëü èãðàåò ïîðàæåíèå êîñòíîìîçãîâîãî êðîâåòâîðåíèÿ, ñëèçè-ñòûõ îáîëî÷åê æåëóäî÷íî-êèøå÷íîãî òðàêòà èëè êëåòîê öåíòðàëüíîé íåðâíîé ñèñòåìû.  ñâÿçè ñ ýòèì ëå÷åíèå áîëåçíè ÿâëÿåòñÿ êîìïëåêñíûì è ñòðîèòñÿ â ñî-îòâåòñòâèè ñ åå ôîðìîé, ñòåïåíüþ òÿæå-ñòè è ïåðèîäîì çàáîëåâàíèÿ [1, 21, 33]. Ñëåäóåò èìåòü â âèäó, ÷òî ëå÷åíèþ â èçíà÷àëüíîì ñìûñëå ýòîãî ñëîâàËÅ×ÅÁÍÎ-ÏÐÎÔÈËÀÊÒÈ×ÅÑÊÈÅ ÂÎÏÐÎÑÛ ñîçäàíèå õèìåðíûõ ìîëåêóë, ñî÷åòàþùèõ ñâîéñòâà àãîíèñòîâ ðåöåïòîðîâ íåñêîëü-êèõ öèòîêèíîâ. Ê íàñòîÿùåìó âðåìåíè èçâåñòíû ñëåäóþùèå öèòîêèíîâûå õèìå-ðû, ñîñòîÿùèå èç äâóõ àãîíèñòîâ: ìèåëî-ïîýòèí (ÈË-3 è Ã-ÊÑÔ), ïðîìåãàëîïîý-òèí (ÈË-3 è ÒÏÎ) è ïðîäæåíèïîýïðîìåãàëîïîý-òèí (ëèãàíä flt-3 è Ã-ÊÑÔ).  îïûòàõ íà îá-ëó÷åííûõ ïðèìàòàõ ïîêàçàíî, ÷òî ìèåëî-ïîýòèí ñòèìóëèðóåò ïðåèìóùåñòâåííî ãðàíóëîöèòîïîýç, ïðîìåãàëîïîýòèí – ìåãàêàðèîöèòîïîýç, à ïðîäæåíèïîýòèí îáëàäàåò ïëåéîòðîïíûì ãåìîñòèìóëèðó-þùèì äåéñòâèåì [15, 27]. Íà ôîíå ñóùåñòâåííîãî ïðîãðåññà â èçûñêàíèè öèòîêèíîâ, îñëàáëÿþùèõ ïîñò-ðàäèàöèîííûå íàðóøåíèÿ ãðàíóëîöèòî-è òðîìáîöãðàíóëîöèòî-èòîïîýçà, çíà÷ãðàíóëîöèòî-èòåëüíî ñêðîì-íåå âûãëÿäÿò ðåçóëüòàòû ïîèñêà ñðåäñòâ ëå÷åíèÿ îñòðîé ëèìôîïåíèè, èììóíî-ñóïðåññèè è ïðîëîíãèðîâàííîãî Ò-êëå-òî÷íîãî èììóíîäåôèöèòà.  òî æå âðåìÿ èçâåñòíî, ÷òî çàäåðæêà â ðåãåíåðàöèè CD4+-êëåòîê, âûðàæåííûé äèñáàëàíñ îò-íîøåíèÿ CD4+/CD8+, îãðàíè÷åíèå ñïåê-òðà Ò-êëåòî÷íûõ ðåöåïòîðîâ çíà÷èòåëü-íî ïîâûøàþò ðèñê ðàçâèòèÿ èíôåêöè-îííûõ îñëîæíåíèé â îòíîñèòåëüíî îòäà-ëåííûå ñðîêè äàæå íà ôîíå âîññòàíîâ-ëåííîãî ãðàíóëîöèòîïîýçà [4 , 8].  íàñòî-ÿùåå âðåìÿ íàèáîëåå ïåðñïåêòèâíûìè äëÿ âîññòàíîâëåíèÿ òèìóñíîãî ëèìôî-ïîýçà è, ñëåäîâàòåëüíî, Ò-êëåòî÷íîãî èì-ìóíèòåòà ïðåäñòàâëÿþòñÿ èíòåðëåéêèí-7, ëèãàíä flt-3 ðåöåïòîðà, òèìèêî-ñòðîìàëü-íûé ëèìôîïîýòèí è ôàêòîð ðîñòà êåðà-òèíîöèòîâ [2].  åùå áîëåå îòäàëåííîé ïåðñïåêòè-âå ðàññìàòðèâàåòñÿ âîçìîæíîñòü èñïîëü-çîâàíèÿ öèòîêèíîâ â êà÷åñòâå ñðåäñòâ, ñïîñîáñòâóþùèõ âîññòàíîâëåíèþ ýïèòå-ëèÿ ñëèçèñòîé îáîëî÷êè æåëóäî÷íî-êè-øå÷íîãî òðàêòà ïîñëå ðàäèàöèîííîãî âîçäåéñòâèÿ â äîçàõ, ïðèâîäÿùèõ ê ðàç-âèòèþ êèøå÷íîãî ñèíäðîìà. Òàê, öåëûé ðÿä öèòîêèíîâ (ÈË-1β, ÈË-11, ôàêòîð ñòâîëîâîé êëåòêè è äð.) çàùèùàþò êëåò-êè êëåò-êèøå÷íîãî ýïèòåëèÿ îò ãèáåëè è ïðå-äóïðåæäàåò ïîñòðàäèàöèîííîå îïóñòîøå-íèå êðèïò òîíêîãî êèøå÷íèêà çà ñ÷åò èíãèáèðîâàíèÿ ïðîöåññîâ àïîïòîçà â ýíäîòåëèîöèòàõ ñîñóäèñòîé ñåòè, ïèòàþ-ùåé êðèïòû è âîðñèíêè [3]. Òàêèì îáðàçîì, çà ïîñëåäíèå äåñÿòè-ëåòèÿ, áëàãîäàðÿ ïîÿâëåíèþ ñðåäñòâ ñòè-ìóëÿöèè ñîõðàíèâøåãîñÿ ïóëà ÑÊÊ è ñîâåðøåíñòâîâàíèþ òåõíîëîãèé èõ òðàíñ-ïëàíòàöèè, íàìåòèëñÿ î÷åâèäíûé ïðîãðåññ â ëå÷åíèè îñòðîãî òÿæåëîãî ëó÷åâîãî êîñòíîìîçãîâîãî ñèíäðîìà. Âìåñòå ñ òåì, íåñìîòðÿ íà î÷åâèäíûå óñïåõè â ëå÷åíèè ÎËÁ (ïðåæäå âñåãî, åå êîñòíîìîçãîâîé ôîðìû), ýòà ïðîáëåìà åùå äàëåêà îò îêîí-÷àòåëüíîãî ðåøåíèÿ. Îñíîâíûå ïåðñïåê-òèâû ðàçâèòèÿ äàííîãî íàïðàâëåíèÿ ñâÿ-çàíû ñ ðàñøèðåíèåì àðñåíàëà ñðåäñòâ, óñêîðÿþùèõ ïðîöåññû âîññòàíîâëåíèÿ ãåìîïîýçà â îáëó÷åííîì îðãàíèçìå ïðåæ-äå âñåãî ãåìîïîýòè÷åñêèõ ðîñòîâûõ ôàê-òîðîâ [3, 18].  ñîîòâåòñòâèè ñ ñóùåñòâóþ-ùèìè ðåêîìåíäàöèÿìè èç öèòîêèíîâ äëÿ ëå÷åíèÿ ÎËÁ ëþáîé ñòåïåíè òÿæåñòè ìîãóò ïðèìåíÿòüñÿ Ã-ÊÑÔ è ÃÌ-ÊÑÔ [21, 30, 31, 33]. Ñ ó÷åòîì íàêîïëåííûõ ê íàñòîÿùåìó âðåìåíè äàííûõ ìîæíî ïî-ëàãàòü, ÷òî âêëþ÷åíèå â ýòîò ñïèñîê ïî êðàéíå ìåðå òàêèõ ôàêòîðîâ, êàê ÒÏÎ, ÈË-3 è ÈË-11, ïîçâîëèò (â óñëîâèÿõ îäíîâðå-ìåííîãî èñïîëüçîâàíèÿ âûñîêî-ýôôåêòèâíûõ ñðåäñòâ ïîääåðæèâàþùåé è çàìåñòèòåëüíîé òåðàïèè) ñóùåñòâåííî ïî-âûñèòü êà÷åñòâî ñïåöèàëèçèðîâàííîé ìå-äèöèíñêîé ïîìîùè ïðè òÿæåëûõ è êðàéíå òÿæåëûõ ðàäèàöèîííûõ ïîðàæåíèÿõ.
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