Visceral Pathology in the Wounded with Mine-Blast Injuries and the Contemporary System of Their Medical Rehabilitation

The dissertation is devoted to a comprehensive study of visceral pathology in military servicemen with the consequences of mine-blast injuries and to the improvement of the system of their staged medical rehabilitation. On the basis of clinical and functional examination of the wounded at the hospital, outpatient-polyclinic, and sanatorium stages of rehabilitation, the frequency, structure, and mechanisms of formation of internal organ pathology, nutritional disorders, mental disorders, the general adaptation syndrome, and quality of life in the functional-restorative period of traumatic disease have been investigated. Differentiated programs of medical rehabilitation, based on syndromic-pathogenetic and clinical-functional principles, have been developed and introduced, and the system of monitoring and dispensary dynamic observation of the health status of this contingent has been improved.

Relevance of the problem

Injuries and their consequences occupy one of the leading places in the structure of morbidity and among the causes of mortality in the population. Traumatic pathology is inherent in peacetime but is most characteristic of armed conflicts (E.A. Nechayev et al., 1984; Yu.N. Fokin, 2000; I.M. Chizh, 2000, 2001; A.F. Shepelenko, 2002; A.L. Rakov, 2003; S.P. Baker, 1985; V.C. Baum, 2002).

Traumatic disease in the wounded in contemporary armed conflicts has a number of specific features: frequent development of severe traumatic pathology as a consequence of mine-blast injuries, high prevalence of combined pathology, more severe somatic disorders, disturbances in metabolism and immune status, decreased adaptive capacities of the body, and a 100% need for socio-psychological adaptation (E.V. Gembitskiy et al., 1994; Yu.N. Shanin et al., 1994, 1997; N.M. Kolomoyets, 1994; M.V. Lyamin, 1999; V.K. Brozhko, 2000; V.G. Novozhenov et al., 2001, 2003; E.A. Kopylov, 2003; A.M. Shchegolkov, 2004, 2005; I.G. Bakulin, 2004; M.J. Roy et al., 1998; O. Gilles et al., 2000).

In view of the military and socio-medical significance of trauma and its consequences, the attention of public health authorities and the military medical service is drawn not only to the treatment of the acute phase of the wound process but also to medical rehabilitation — the restorative treatment of local and general forms of post-traumatic pathology.

The attention of internists to the pathology of internal organs in the wounded was attracted mainly in the early post-wound period and subsequently at the sanatorium stage. The considerable period of the hospital stage of rehabilitation of the wounded, however, has practically not been studied. Meanwhile, it is precisely the hospital stage that should lay the foundations for the rehabilitation of this contingent.

Data on the regularity and frequency of development of internal organ pathology in trauma in relation to the severity of the trauma itself are contradictory (E.V. Gembitskiy, L.M. Klyachkin, M.M. Kirillov, 1994; Yu.N. Shanin, 1995; L.R. Gadzhiyeva, 2004). In addition, the contemporary literature does not create a coherent picture of internal organ pathology in the wounded, especially in the long-term period after trauma, and does not fully cover the problems of its diagnosis and treatment, medical rehabilitation, and dispensary dynamic observation of convalescents at the outpatient-polyclinic stage (L.M. Klyachkin et al., 2002).

No system of registration and dispensary observation of the wounded in armed conflicts has been developed, and adequate information support on the state of health and rehabilitation of disabled combatants is lacking (A.S. Kobzev, 2000; A.G. Chepurnoy, 2002, 2004).

The heterogeneity of the composition of the wounded with the consequences of mine-blast injuries admitted to the stages of medical rehabilitation, the diversity of the clinical state of convalescents, the background and concomitant diseases they have, and the lack of scientifically grounded, differentiated treatment-and-rehabilitation complexes and programs for these contingents of victims necessitate the search for new organizational approaches, as well as the improvement of the existing system of application of physical, psychological, traditional, and pharmacological methods of treatment.

Aim of the study: on the basis of studying the features of visceral pathology and the mental state of the wounded with the consequences of mine-blast injuries in the convalescence period of traumatic disease, to develop rehabilitation programs using contemporary medical technologies and to improve the system of their staged medical rehabilitation, making it possible to enhance the quality and effectiveness of specialized medical care for the wounded.

Objectives of the study:

1. To study the frequency, structure, and features of pathological changes in internal organs in the wounded with mine-blast injuries in the functional-restorative period of traumatic disease.

2. To assess the trophic status and to identify the frequency and mechanisms of formation of nutritional insufficiency in the wounded with contemporary mine-blast combat trauma.

3. To investigate the features of mental disorders in military servicemen who have sustained mine-blast injuries.

4. To study the main regularities of the course of the general adaptation syndrome of the body in response to trauma and to assess the quality of life of the wounded.

5. To develop a system of monitoring and dispensary dynamic observation of the health status of the wounded with visceral pathology.

6. To assess the influence of professional retraining of the wounded with mine-blast injuries on the results of their social readaptation.

7. To study the effectiveness of existing programs of medical rehabilitation of the wounded and to develop differentiated rehabilitation programs for convalescents after mine-blast injuries at the stages of medical rehabilitation, based on syndromic-pathogenetic and clinical-functional principles.

8. To assess the effectiveness of the proposed rehabilitation programs in terms of immediate and long-term results.

Scientific novelty.

The frequency, structure, mechanisms, and regularities of formation of visceral pathology, as well as the clinical and pathogenetic features of the course of traumatic disease in the wounded with mine-blast injuries in the functional-restorative period at the stages of medical rehabilitation (hospital, outpatient-polyclinic, and sanatorium), have been studied.

Informative criteria for the diagnosis of visceral pathology in the wounded in the functional-restorative period of traumatic disease have been developed using contemporary diagnostic methods.

The long-term influence of mine-blast injuries on the structure of visceral pathology, mental disorders, nutritional status, adaptation, and quality of life in military servicemen affected in combat operations has been investigated.

The organizational and methodological principles of medical rehabilitation of the wounded have been substantiated with reference to the specific tasks of restoring their health.

The influence of vocational training (retraining) of the wounded in the process of rehabilitation on the results of their social readaptation has been studied.

New methods of diagnosis, treatment, and rehabilitation, as well as differentiated programs of staged medical rehabilitation of the wounded with internal organ pathology, have been developed, tested, and introduced into practice, and their effectiveness has been studied.

The system of monitoring and dispensary dynamic observation of the health status of the wounded with visceral pathology has been studied and improved.

Practical significance.

The frequency and structure of somatic and mental pathology in the wounded in the functional-restorative period of traumatic disease have been studied, which makes it possible to predict the volume of medical care and the specifics of medical support at the stages of medical rehabilitation.

The mechanisms of formation of visceral pathology in the wounded in the convalescence period of traumatic disease have been established.

The expediency of optimizing the staged system of medical rehabilitation of the wounded with internal organ pathology and the necessity of improving the existing complex of rehabilitation measures through a syndromic-pathogenetic approach have been demonstrated. Criteria for the transfer of convalescents to the stages of medical rehabilitation have been worked out and scientifically substantiated. The ways of optimizing the staged system of rehabilitation of the wounded in traumatic disease have been determined.

New differentiated programs of medical rehabilitation of the wounded at the hospital, outpatient-polyclinic, and sanatorium stages have been developed and introduced on the basis of syndromic-pathogenetic and clinical-functional approaches, which contribute to the timely and adequate prescription of individual complexes of medical and medico-psychological rehabilitation.

A system of monitoring and dispensary dynamic observation of the health status of the wounded with visceral pathology at the outpatient-polyclinic stage has been proposed and adopted for implementation.

The materials of the dissertation have been used in the development of the "Concept of Medical Rehabilitation in the Armed Forces of the Russian Federation," in carrying out the research project "Creation of the All-Army Register of Disabled Persons Due to Military Trauma, Participants in Combat Operations of the Ministry of Defense of the Russian Federation," and in the elaboration of guiding documents on medical rehabilitation in the Armed Forces of the Russian Federation (Directives of the Chief of the Main Military Medical Directorate of the Ministry of Defense of the Russian Federation).

On the basis of the data obtained, methodological recommendations "Medical Rehabilitation in Traumatic Disease" (Moscow, 2002) have been prepared and published, a chapter for the methodological manual for physicians "Medical Rehabilitation in the Armed Forces of the Russian Federation" (Moscow, Voyenizdat, 2003) has been written, and teaching-methodological manuals have been developed.

The results of the investigations make it possible to improve the clinical training of medical specialists working in rehabilitation institutions and to optimize the treatment-and-diagnostic process at the stages of medical rehabilitation.

The main propositions of the conducted study can be used in organizing the staged medical rehabilitation of the wounded and victims as a result of combat operations, accidents, catastrophes, and natural disasters.

Implementation of the results of the work

The results of the study and the developed rehabilitation programs have at present been implemented and are being applied in the practical work of the Burdenko Main Military Clinical Hospital, the 3rd Vishnevskiy Central Military Clinical Hospital, the 6th Central Military Clinical Hospital, the 25th Central Military Clinical Hospital, the Pyatigorsk Central Military Sanatorium, the Volga Military Sanatorium, the 52nd Consultative and Diagnostic Center of the Ministry of Defense of the Russian Federation, and are also used in the educational process at the departments of the State Institute for Advanced Medical Training of the Ministry of Defense of the Russian Federation.

Approbation of the work

The materials of the study have been reported and discussed at:

— departmental meetings of the Department of Medical Rehabilitation and Physical Methods of Treatment of the State Institute for Advanced Medical Training of the Ministry of Defense of the Russian Federation (2001, 2002, 2003, 2004, 2005);

— the 1st All-Russian Forum "3rd Millennium. Ways to the Health of the Nation" (Moscow, 2001);

— the 11th National Congress on Respiratory Diseases (Moscow, 2001);

— the 5th International Conference "Contemporary Technologies of Restorative Medicine" (Sochi, 2002);

— the 12th National Congress on Respiratory Diseases (Moscow, 2002);

— Meetings of the Command Staff of Military Sanatoria (Pyatigorsk, 2002);

— the 2nd All-Russian Scientific and Practical Conference "Contemporary Problems of Restorative Medicine and Rehabilitation of Persons of Hazardous Professions" (Moscow, 2002);

— the 108th Meeting of the Scientific Society of Military Field Surgeons (Moscow, 2003);

— Scientific and Practical Conferences of the State Institute for Advanced Medical Training of the Ministry of Defense of the Russian Federation (Moscow, 2003, 2004, 2005);

— the 2nd Specialized Exhibition "Russian Shield" (Moscow, All-Russian Exhibition Center, 2003);

— the 3rd All-Russian Scientific and Practical Conference "Contemporary Approaches to Methods of Pharmacological Correction in the Professional and Medical Rehabilitation of Persons of Hazardous Professions" (Moscow, 2003);

— the All-Russian Scientific and Practical Conference "Methods, Norms, and Technologies of Rehabilitation of Persons Who Suffered in the Performance of Military Service Duties (Official Duties): Experience and Problems of Use, Prospects for Development" (M.A. Likhodey Center for Restorative Therapy, Ruza, 2004);

— the All-Russian Scientific and Practical Conference "Contemporary Approaches to Medico-Psychological Rehabilitation of Persons of Hazardous Professions" (Moscow, 2004);

— the 2nd International Congress "Restorative Medicine and Rehabilitation 2005" (Moscow, 2005);

— the 15th National Congress on Respiratory Diseases (Moscow, 2005).

Publications. On the topic of the dissertation, 54 scientific works have been published, including 9 in central print. A methodological manual for physicians (in 3 parts), 2 methodological recommendations, and 3 teaching-methodological manuals have been written. Monographs have been published in co-authorship: "Medical Rehabilitation of the Wounded with Visceral Pathology at the Sanatorium Stage" (2004) and "Medical Rehabilitation of Participants in the War in Afghanistan" (2005).

Volume and structure of the work. The dissertation is set out on 293 pages of typescript and consists of an introduction, 5 chapters, a conclusion, conclusions, practical recommendations, a bibliographic index, and an appendix. The work is illustrated with 81 tables and 13 figures. The list of references includes 238 domestic and 100 foreign sources.