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История реконструктивной хирургии аорты и аортального клапана

Хирургия аорты остается наиболее сложным и бурно развивающимся разделом сердечно-сосудистой хирургии. История хирургии аневризм аорты прошла несколько этапов: от нереконструктивного, когда подручными средствами добивались уменьшения риска аорта-ассоциированных осложнений, не удаляя аневризму, до рентгенэндоваскулярного. Однако открытые вмешательства до сих пор остаются «золотым стандартом» хирургии аорты. Совершенствуются методы защиты внутренних органов, расходные материалы. Также сложный путь прошла хирургия аортального клапана, являющегося неотъемлемой частью восходящей аорты. В обзоре прослежены основные успехи в реконструктивной хирургии пороков аортального клапана и заболеваний аорты. Упоминаются только первые в своем роде вмешательства, закончившиеся улучшением состояния пациентов, выполненные великими новаторами своего времени. Отражен вклад советских и российских хирургов в мировую хирургию аорты.Поступила в редакцию 11 июля 2017 г. Принята к печати 21 июля 2017 г.ФинансированиеИсследование не имело спонсорской поддержки.Конфликт интересовАвторы заявляют об отсутствии конфликта интересов. Вклад авторовКомаров Р.Н.: концепция исследования, научное руководство, редактирование статьи; Каравайкин П.А.: набор, анализ, обработка материала, написание статьи; Мурылев В.В.: набор материала.</p

The First-Stage Treatment Аlgorithm for Deep Infected Total Hip Arthroplasty

Background. Periprosthetic infection after total hip arthroplasty is a relatively common and severe complication. A two-stage revision with the temporary use of a spacer is the gold standard treatment for the deep infected total hip arthroplasty. Some authors report mechanical complications associated with spacers, which can lead to a poor functional outcome. Therefore, the aim of the study was to analyze the effectiveness of the first-stage of treatment of hip PJI with a two-stage method and to develop an spacer application algorithm in order to achieve the optimal functional result.Material and Methods. Between 2015 and 2017, 38 patients with deep periprosthetic infection received an articulation spacer as part of a two-stage protocol in Botkin Moscow City Hospital. The mean age was 60.5 (interquartile range from 5 2 to 69) years. Five different types of spacers were us ed in the study, selected individually according to theW. Paprosky acetabular defects classification. The overall frequency of complications was evaluated.Results. The overall periprosthetic infection treatment effectiveness was 92.1%. There was the recurrent infection in 3 patients (7.9%), in 2 (5.26%) cases microbial associations were founded. Mechanical complications occurred in 8 (21%) patients. Spacer dislocation occurred in 4 (10.4%) cases, spacer fracture in another 2 (5.2%). There were also 2 cases of protrusion into the pelvis (5.2%).Conclusions. The first stage a two-stage revision hip arthroplasty should be carefully plarmed. To choose the appropriate spacer we proposed an algorithm based on our data to achieve a better functional result

Importance of the Algorithm for Diagnosis of Late Deep Periprosthetic Hip Infection

Relevance. Late deep periprosthetic infection (PJI) of the hip joint is a serious complication after arthroplasty which takes the lead among the world reasons for revision. Accurate diagnostics allows to achieve good results and select a proper treatment tactics. Purpose of the study — to evaluate the efficiency of diagnostics algorithm for late deep PJI and impact of the microbial landscape on the risk of infection recurrence. Materials and methods. The authors evaluated two groups of patients who underwent revision in the period from 2002 to 2014 and from 2015 to 2018. The first (retrospective) group included 144 patients who were not diagnosed for late deep PJI. The second (prospective) group included 157 patients who underwent detailed diagnostics for late deep PJI based on the algorithm including the analysis of x-rays, pelvic CT, triple evaluation of ESR and CRP, puncturing of affected joint and microbiology examination. The authors assessed the microbial landscape in 51 patients with late deep hip PJI. Results. In the first group 12 patients (8.3%) underwent sanation and spacer insertion during first stage of treatment, 46 patients (59.7%) after revision demonstrated positive intraoperative cultures confirming septic etiology of implant loosening, 19 patients (24.67%) had no flora growth, and no intraoperative microbiological examination was done for remaining 67 patients (46.52%). In the second group after detailed diagnostics 51 patients (32.4%) underwent removal of prosthesis and spacer insertion in the first stage, other 13 patients (8.2%) featured flora growth after revision, remaining 93 patients (59.2%) had no flora growth after revision. Recurrent PJI was observed in 21 patients (14.5%) in the first group, and in 10 patients (6.3%) in the second group. In the second group recurrent PJI was reported in 40% of patients due to microbial associations, in 30% — due to MRSA, in 20% — due to culture negative bacteria and in 10% — due to S. aureus. Conclusion. Triple examination allows to obtain an accurate diagnosis and isolate the pathogen for deep PJI. Application of such diagnostics algorithm allows to reduce 2.1 times the risk of recurrent deep PJI and to scale down 4 times the detection of type IV infection by Coventry–Tsukayama classification

Semuloparin for prevention of venous thromboembolism after major orthopedic surgery: Results from three randomized clinical trials, SAVE-HIP1, SAVE-HIP2 and SAVE-KNEE

Background: Semuloparin is a novel ultra-low-molecular-weight heparin under development for venous thromboembolism (VTE) prevention in patients at increased risk, such as surgical and cancer patients. Objectives: Three Phase III studies compared semuloparin and enoxaparin after major orthopedic surgery: elective knee replacement (SAVE-KNEE), elective hip replacement (SAVE-HIP1) and hip fracture surgery (SAVE-HIP2). Patients/Methods: All studies were multinational, randomized and double-blind. Semuloparin and enoxaparin were administered for 7-10days after surgery. Mandatory bilateral venography was to be performed between days 7 and 11. The primary efficacy endpoint was a composite of any deep vein thrombosis, non-fatal pulmonary embolism or all-cause death. Safety outcomes included major bleeding, clinically relevant non-major (CRNM) bleeding, and any clinically relevant bleeding (major bleeding plus CRNM). Results: In total, 1150, 2326 and 1003 patients were randomized in SAVE-KNEE, SAVE-HIP1 and SAVE-HIP2, respectively. In all studies, the incidences of the primary efficacy endpoint were numerically lower in the semuloparin group vs. the enoxaparin group, but the difference was statistically significant only in SAVE-HIP1. In SAVE-HIP1, clinically relevant bleeding and major bleeding were significantly lower in the semuloparin vs. the enoxaparin group. In SAVE-KNEE and SAVE-HIP2, clinically relevant bleeding tended to be higher in the semuloparin group, but rates of major bleeding were similar in the two groups. Other safety parameters were generally similar between treatment groups. Conclusions: Semuloparin was superior to enoxaparin for VTE prevention after hip replacement surgery, but failed to demonstrate superiority after knee replacement surgery and hip fracture surgery. Semuloparin and enoxaparin exhibited generally similar safety profiles. \ua9 2012 International Society on Thrombosis and Haemostasis