Lecture on "Clinical supervision and rehabilitation of sickly children as a general

practitioner"

Lecturer Ph.D. G.M. MuldaevaDiscipline, "General medical practice"Specialty 051 301 "General Medicine"

course V

The purpose of the lecture: To familiarize students with the basic principles, forms and organization of rehabilitation of sick children in outpatient, with the structure of the main tasks and the organization of the Department of Rehabilitation, Rehabilitation characteristics of sickly children.

• Plan lectures:• The concept of rehabilitation, its types.• Stages of rehabilitation, the amount of medical care.• Aims and objectives department of rehabilitation. Structure and capabilities. Hygiene

requirements, staffing, schedule, responsibilities of employees. The volume of diagnostic and therapeutic procedures, monitoring the effectiveness, quality of rehabilitation.

• Definition of "sickly child", particularly their immune system and non-specific defenses. Factors contributing to the formation of groups of sickly children. Social and hygienic their significance.

• Especially the approaches to the rehabilitation of these days. Therapeutic and preventive measures. Opportunities for rehabilitation clinics CHBD. Organization of the conditions for rehabilitation of preschool institutions and homes. Spa group. The physiological significance of gymnastics, massage, and tempering CHBD. Evaluating the effectiveness of the work done for the rehabilitation and improvement of CHBD. Clinical examination.

• The most important stage of follow-up is the rehabilitation or restorative treatment. Under the rehabilitation understood as a set of medical, social, economic and other measures aimed at the most rapid and full restoration of health of the sick and his age to the usual conditions of life, work, study, and in the absence of such a possibility - ensuring stable compensation of disturbed functions and adapt to new conditions of existence. Medical. Rehabilitation is the result of merging the interests of proper medicine, social medicine and sociology. It replaced the main curative medicine.

In the development practice of medicine can be set three major periods:

• Period curative medicine when all the forces of scientists and doctors were sent to search for treatments already developed disease

• 2nd most progressive period was the period of preventive medicine

• 3rd period is rehabilitation medicine. This is not a rejection of preventive medicine for its development.

• Rehabilitation as a separate branch of medicine began to develop after the 2nd World War in connection with the problem of huge trudoustroy1stva disabilities. UN has developed a special rehabilitation program, which is carried out by WHO.

The guiding principles of rehabilitation should read:

• The principles of unity of interests between doctor and patient

• The principles of integrated application of diverse• The principle of individual approach to the patient, taking

into account its characteristics and living conditions.• The principle of continuity, phasing of rehabilitation.• The basic principle of treatment of patients with chronic

diseases - in various stages of succession. Children's Clinic - a hospital-health center - a special school and children. orchards - a family health center.

The first stage - clinical.

• At this stage, provided not only the clinical recovery, and restoration of function of the affected systems, the preparation of the whole body of the patient to the next step.

• The objectives of this phase consists of the removal of the etiological factor, the reduction and elimination of morphological changes in affected organs, compensation, then the elimination of inadequate organ function. At this stage, are important tasks, such as calming the child, the normalization of its emotional tone, raising confidence in a successful recovery.

• In the acute phase of rehabilitation activities will be conducted either in hospital or at home.

• To solve the problems of rehabilitation in the first stage are used all the means: medication, physical therapy, therapeutic exercises.

• Of great importance is diet, protective mode. In a hospital on this issue is difficult because of the simultaneous stay in it for many children.

• The organization of the environment sick child at home confined mainly to support him no rest, hygiene and making some additional amenities.

• The children particularly hard period of adjustment occurs in a hospital, so important is the correct age-specific placement of children on the wards. It is desirable to take into account the psychological compatibility.

• The first phase of rehabilitation ends when the child recovers, and restoring the function of the affected organ or a sufficient compensation for the lost function due to illness.

• Successful completion of the clinical stage of rehabilitation of a number of indicators. The child does not show up dolzhn6o nor any signs of activity in the process of clinical and laboratory evaluation of temperature-no complaints. Responses to the functional tests with measured physical. Adequate load requirements of the expanding mode.

• Epstein & Hundert, JAMA 2002; 287:226-235

The second phase of rehabilitation

• The second phase of rehabilitation - a local nursing home. It is crucial to achieving these goals of rehabilitation as the normalization function of the affected system. At this stage, as provided by the elimination of pathological changes characteristic of the period of residual effects.

• Particular attention is paid to the restoration and expansion of physical and mental activities in accordance with the adults and individual abilities.

• An important task is to normalize the reactivity of the organism.

• Sanitary stage is in spec. Sanatorium, and for some categories of patients in a rehabilitation ward or in the center.

• Drug therapy at this stage, retreating to the 2nd plan, and the main importance is the diet regime, tempering procedures, physical therapy and exercise therapy.

• In the second phase focuses on the struggle with foci of chronic infection and strengthening therapy (ENT consultation, the dentist). At this stage, should be carried out and fight with a reaction to the disease, the host sometimes, especially in children - Neurology - abnormal shape to deal with these phenomena should be used educational interventions, the amount of which is determined psychoneuropathology. In severe cases, used sedatives.

• Completion rates for the sanatorium stage of rehabilitation should be considered as absence of clinical, radiological and other signs of a pathological process

• Often, children with chronic diseases may be directed to the resorts. Circle of children in need of spa treatment should be restricted. It may be not only useless, but harmful to the child. Spa treatment provides for the elimination of general and local inflammatory activity and termination of relapses or complete cure of the disease, hardening. The resort uses potent factors Thalasso balneolimanoterapy, climatic and other factors that may move the child with particular training in the presence of a sufficient reserve of strength. The negative factor of spa treatment and adaptation to different climatic zone. Resort stage can be considered a pioneer camp sanitary type, if it uses the factors of treatment, close to the resort (mineral water can be bottled, massage, exercise therapy, physiotherapy, tempering, educational interventions, mode).

The third stage of rehabilitation of the adaptation:

• At this stage a full recovery is achieved by the child's health, ensuring full age to share a common living conditions, education, sports. It is unacceptable fatigue of the child.

• The definition of "sickly child", particularly their immune system and non-specific defenses. Factors contributing to the formation of groups of sickly children. Social and hygienic their significance.

• As an example, consider the form and principles of rehabilitation and often long-term sick children (CHDBD) - one of the most important medical and social problems of Pediatrics. In the Gorky Institute of Pediatrics in a large statistical material based and calculated the following age criteria for the determination of groups CHBD.

• 1 year of life - 4 or more acute cases per year;• 1-3 years of life - 6 and more acute cases per

year;• 3-4 years - 5 or more acute cases per year;• 4-5 years - 4 and more acute cases per year;• 6 or more years of life - 3 or more acute cases

per year;

• It is well known that acute respiratory infections are the most frequent diseases in both children and adults. But the highest incidence of respiratory infections observed in preschool children attending organized groups. Frequent acute respiratory disease in children now represent not only medical but also social and economic problem.

• On the other hand, the contact and interaction with respiratory infections - the necessary conditions for the formation of the immune system of the child, its acquisition of immunological expertise required to adequately respond to microbial aggression. However, frequent respiratory infections, following one after another, certainly have a negative impact on the child.

• Thus, the selection of dispensary CHBD is timely and relevant, but in each case should be conducted a comprehensive survey of the child to clarify the reasons for his high level of respiratory disease. Clinical supervision for children who have recurrent episodes of respiratory infections are caused by persistent changes in immune system, congenital or hereditary diseases should be conducted in strict accordance with the underlying disease.

• The main causative agents of acute respiratory infections are a variety of viruses tropic for airway epithelium and contribute to their secondary colonization by bacteria. Viral infections damage the airway epithelium and causes inflammation of the mucous membrane. For inflammation of the respiratory tract is characterized by increased production of viscous mucus, which manifests a cold and cough. Promotes adhesion of viscous secret (adhesion), agents of respiratory infections in the mucous membranes of the respiratory tract, which creates favorable conditions for bacterial superinfection. In turn, microorganisms and their toxins impair the movement of the cilia of the epithelium, violate the drainage function of the bronchial tree, reduce the bactericidal properties of bronchial secretions and local immune defense of the respiratory tract at high risk of a protracted and chronic course of the inflammatory process. Damaged bronchial epithelium has an increased sensitivity of receptors to external influences, which greatly increases the risk of bronchospasm and bacterial superinfection.

• The main bacterial pathogens of acute respiratory infections are pneumotrop microorganisms including pneumococcus and other Gram-positive cocci, rod gemofilyus influenzavirus, moraksella kataralis, atypical pathogens (Mycoplasma, hlamidofila pneumonia), etc. It is believed that the primary viral infection often leads to the activation of endogenous pathogenic flora. The reason for this transformation easier pathogenic microorganisms in a number of children associated with the individual characteristics of immune response, a violation of the barrier function of the respiratory tract, reduced local immunity, as well as superinfection with bacterial agents. Joining a bacterial infection leads to increased disease severity and may be an underlying cause of adverse outcome of the disease. The nature of the clinical picture of acute respiratory disease is largely due to pathogenic properties of agent. But we know that the younger the child, the less specific symptoms has a disease.

• Thus, an infectious inflammation is the major pathogenetic link clinical manifestations of acute respiratory infections. The development of inflammation of the mucous membranes of the upper and lower respiratory tract contributes to hypersecretion of viscous mucus, swelling of the mucous membrane forming the respiratory tract, disruption of mucociliary transport and bronchial obstruction. This leads to nasal congestion, nasal secretions secretion, hyperemia throat, sore throat, swollen tonsils, hoarseness, coughing and other symptoms of acute respiratory disease, including acute bronchitis and laryngotracheitis. Some patients develop obstructive bronchitis.

• It is known that so far there are no universal and safe chemotherapeutic agents that are effective against most respiratory viruses. Antiviral chemotherapy drugs (ribavirin, and others) in children is used only for severe acute respiratory viral etiology established. The use of antiviral ointments such as oxolinic can only be regarded as a preventive tool, but the appointment of such drugs as Remantadin, children of the early years is contraindicated, owing to its high toxicity and lack of effectiveness.

• Fairly widely used in viral respiratory infections found interferon preparations, which as protective factors and means of maintaining immunity have the widest range of preventive and therapeutic actions. Interferons - the natural protective factors, that is produced by the body when it is in contact with infections of various origins (viruses, bacteria, fungi, etc.). Consequently, the use of interferon drugs completely natural for humans. In addition, due to their biological characteristics impact of infectious agents, interferons are universal protectors, they are effective against all respiratory viruses. In addition to antiviral and antibacterial effects of interferon preparations increase their own defenses and prevent the harmful effects of radiation on the human body.

• It is obvious that in practical public health interferon preparations are widely used. First it was drugs leukocyte interferon produced from donated blood. Subsequently, the development of biotechnology has allowed a recombinant (genetically engineered) preparations of human interferon in many respects superior to the first-generation drugs. Currently, there are quite a lot of preparations of recombinant interferons of both local and foreign production: Viferon, Reaferon, Grippferon, Realdiron, Intron A, Roferon-A, etc.

• The most effective and safe in children are recombinant interferon preparations in combination with antioxidants, such as domestic product "Viferon." Dosage forms Viferon in the form of rectal suppositories (suppositories), gel and ointment provide a simple, safe and painless method of administration, which is especially important in pediatrics and outpatient care. Viferon protects cells from damage that activates the immune system, has antioxidant activity and prevents aging. Viferon has not only severely immuno directed substitution, but also broad enough immune modulation and protective effect. Viferon can take over, including patients with allergies, pregnant women and children, including newborns and premature babies.

• Immunocorrective and immunomodulatory drugs in ARI have both preventive and curative effect. There is strong evidence of a high therapeutic effect in treating children with influenza and SARS are inducers of endogenous interferon (Amixin, Arbidol, Cyclopheron). In this Arbidol can be used in children from 2 years of age, Cyclopheron approved for use in children older than 4 years, and Amixin - only for children older than 7 years. Of course, synthetic immunostimulants, drugs thymic origin, and some others have strong effects on the immune system, but the decision about the necessity of their use, particularly in children, should be made only after clinical and immunological examination, clarify the type of immune system dysfunction, and with a clear clinical and immunological testimony. In this therapy should be conducted herself with the necessary clinical monitoring and immunological control.

• Antibiotic therapy with systemic antibiotics is ineffective and ARD shown very rarely, not more than 10% of all cases. Appointing a systemic antibiotic without adequate grounds, the physician increases the risk of side effects, violates microbiocenose, reduces immunity and the spread of drug resistance. Local antibiotic therapy provides a direct impact on the source of infection, creating an optimal concentration of the drug and has no systemic side effects. One of the best local antibacterial drugs for the treatment of acute respiratory disease in children and adults is phuzaphunzhin (bioparoks), which is unique because of its dual action: antimicrobial and anti-inflammatory.

• For inflammatory diseases of the respiratory tract characterized by change in sputum viscosity and reduced mucociliary clearance. If the peristaltic movements of small bronchi and ciliary epithelium activities do not provide the necessary drainage, cough develops. Consequently, the cough - it's a protective reflex, designed to restore airway patency. Obviously, the need to suppress cough in children with true antitussive drugs with pathophysiological position is not justified. The aim of rational therapy is thinning mucus, reducing its adhesiveness (viscosity) and increase thereby the effectiveness of cough. For this purpose, drugs that stimulate expectoration (herbal, alkaline solutions) and mucolytics (bromhexine, Ambroxol, NAC, etc.). These drugs improve mucociliary clearance and thereby help to reduce inflammation of the mucous membranes of respiratory tract.

• However, the use of mucolytic and expectorant drugs in children with respiratory infection can not always eliminate the "vicious cycle" of inflammation of bronchi. In recent years, as a nonspecific anti-inflammatory drugs for respiratory diseases in children has been used successfully fenspiride (Erespal), which has a distinct tropism for the respiratory system. Anti-inflammatory effect Erespala improves mucociliary clearance and resolution of cough, reduces the effect of the major pathogenetic factors of respiratory infections, which promote inflammation, mucus hypersecretion, hyperresponsiveness and bronchial obstruction. The drug is well tolerated in children of different age groups, including infants, and usually does not cause side effects.

• The main methods of increasing the resilience of the child infectious agents is hardening. Systematic contrasting air or water hardening is accompanied by increased resistance to temperature fluctuations of the environment and increased immunological reactivity. Adaptive capacities of children respond well to training. The use of any method of hardening Advances apparatus thermoregulation and enhances the organism's adaptation to the changing temperature conditions. Hardening does not require very low temperatures, the contrast is important and systematic influence of the procedures. Well quenched impact on soles of feet, and gradually - for all the skin of the trunk and extremities. The maximum duration of tempering procedures should not exceed 10-20 minutes, much more important than his regular and gradual.

• Given the leading role in the development of immune dysfunction, increased susceptibility of children's organism to respiratory infections, except for complex restorative measures to prevent use a variety of immunomodulatory drugs. However, most authors stress that the use of immunomodulatory drugs for the prevention of respiratory infections in sickly children should be conducted against the background that we comply with the general principles of prevention and rehabilitation.

• It was shown that a combination of sickly children of local tempering procedures stop and nasal restored after 3-4 months of nasal secretions cytological parameters. Tempering procedures combine well with the conduct of exercises and massage of the chest. Tempering after non-severe acute respiratory disease can resume (or begin) in 7-10 days, with a disease with a duration of reaction temperature over 4 days - 2 weeks, and after a 10-day fever - in 3-4 weeks. The efficiency of hardening can be evaluated no sooner than 3-4 months, and the maximum effect was observed in one year from the start of the regular procedures.

• Currently, interest has grown in disease-modifying drugs of bacterial origin, has also the effect of vaccination, which not only increases the activity of nonspecific factors of immune protection, but also promote the formation of a specific immune response to the most significant bacterial pathogen pneumotrop. Among modern immunomodulators of bacterial origin isolated highly purified bacteriolysates, membrane fractions and ribosomal Ribomunil immunomodulator, which includes not lysates of bacteria, and their ribosomes and fragments of cell wall (proteoglycans), which determines the high clinical and immunological effectiveness and reactogenicity of a minimum of the drug, which combines properties of the vaccine and non-specific immunomodulator.

• In conclusion, we must emphasize once again that "often ill children" - a group of follow-up, quite numerous among preschool children living in ecologically unfavorable regions and attending day care centers. These kids need to conduct regular, comprehensive prevention and the development of acute respiratory infections - in a timely and adequate therapy.

Literatures

• State Programme "Health of the Nation", Astana 1998.-84s.• Polyclinic pediatrics / ed. Prof. E.T. Dadambaeva - Almaty:

Anuar, 1999.-196s.• Polyclinic pediatrics: Textbook. Benefit / EP Sushko, V.

Novikov, ZE Petukhov and others - MH.: Stitch. wk., 2000.-301s.

• USSR Ministry of Health Order № 60 from January 19, 1983 "On further improvement of outpatient care for children's population in cities.“

• Shabalov N.P. Childhood illnesses. - St. Peter Com, 1999. - 1088s.

Questions

• The concept of rehabilitation, its types.• List the stages of rehabilitation.• Aims and objectives department of

rehabilitation.• The concept of "often ill child".