The purpose of the study was to improve the results of treatment of post-traumatic reactive hepatitis in victims of gunshot wounds by improving the prognosis, early diagnosis and treatment. Materials and methods. A retrospective analysis of 233 medical records of inpatients of wounded military persons of 2014-2020 hospitalized in medical institutions of the Ministry of Defense of Ukraine for more than 14 days. All victims were examined in the laboratory using unified methods of laboratory tests. The value of relative risk was calculated. The probability of liver dysfunction was assessed using binary logistic regression with a comprehensive analysis of the values of individual indicators (risk factors). The informativeness of the forecast was determined by sensitivity and specificity, which were calculated on the basis of true and false (positive and negative) forecasts. Additionally, the quality of the binary logistics model was tested by ROC analysis to determine the area under the ROC-curve (AUC). Results and discussion. There was a significant difference in the frequency of detection of most of the analyzed indicators: mine-explosive type of injury; presence of abdominal trauma, including liver trauma, multiple soft tissue trauma, traumatic shock and anemia (p <0.05 according to Fisher's exact test). Skeletal trauma occurred in both subgroups with almost the same frequency, thoracic trauma more often, but not significantly (p >0.05 according to Fisher's exact test). All studied indicators had a significant risk of developing reactive hepatitis (upper and lower limits of 95 % confidence interval greater than 1.0). Anaemia had the greatest impact (relative risk greater than 5.6 with a specificity of 0.951), followed by multiple soft tissue injuries (more than 3.8 with a specificity of 0.833), traumatic shock (more than 3.7 with a specificity of 0.747). Relative risk values of the mine-explosive nature of injuries, abdominal trauma and liver trauma were in the range of 2.0-2.7. Using the method of Wald's exclusion, a model of reactive hepatitis prognosis was created with a prognostic value of a positive result of 78.9 %, a prognostic value of a negative result of 95.1 %, specificity of 87.5 %, and sensitivity of 91.1 %. The results of the ROC analysis were evaluated based on the area under the ROC-curve (AUC), which was 0.879 (95 % CI 0.810-0.929) at a significance level of <0.001. The cut-off value is 0.5. For the convenience of usage of the described model, the mobile application was created. Conclusion. The most significant risk factors for reactive hepatitis after gunshot wounds are anaemia, multiple soft tissue injuries, and traumatic shock. The model for predicting the development of reactive hepatitis after a gunshot wound, made in the form of a mobile application, in which the presence of abdominal trauma, multiple soft tissue trauma, traumatic shock and anaemia are used as predictors, has a specificity of 87.5 % and sensitivity of 91.1 %

Актуальність. У структурі сучасного травматизму все більшої актуальності набувають вогнепальні кульові та мінно-вибухові поранення. Вогнепальні поранення характеризуються важким перебігом із частим розвитком місцевих та загальних ускладнень, серед яких важливе місце посідає печінкова дисфункція, що найчастіше проявляється збільшенням маркерів цитолізу в плазмі крові — трансаміназемією. Метою дослідження було визначення діагностичного значення трансаміназемії у постраждалих із вогнепальними пораненнями. Матеріали та методи. Здійснено ретроспективний аналіз 373 історій хвороби військовослужбовців, поранених під час озброєного конфлікту на Сході України в 2014–2020 рр., які знаходились на стаціонарному лікуванні в Національному військово-медичному клінічному центрі та у військово-медичних клінічних центрах Північного, Південного, Східного регіонів Міністерства оборони України. Проаналізовано концентрацію аланінамінотрансферази (АЛТ) та аспартатамінотрансферази (АСТ) у 1–2, 3–13 та на 14-ту добу і більше після травми. Результати. Установлено, що в постраждалих із вогнепальними пораненнями вже в 1-шу — 2-гу добу після травми майже у двох третинах випадків спостерігається збільшення концентрації амінотрансфераз. Через два тижні та більше значне підвищення рівня трансаміназ (більше 80 ОД/л) зберігається більш ніж у 40 % поранених. На всіх етапах дослідження більш значимо збільшувалась концентрація АСТ порівняно з концентрацією АЛТ. Коефіцієнт Де Рітіса в першому та другому періоді спостереження в більшості випадків був більше 1,3, а через два та більше тижні після травми значно зростала кількість поранених із коефіцієнтом Де Рітіса менше 0,8. Висновки. 1. Трансаміназемія в постраждалих із вогнепальними пораненнями в посттравматичному періоді спостерігається майже в 75 % випадків. 2. Причиною трансаміназемії в поранених може бути ураження не тільки печінки, але й інших тканин, що були ушкоджені під час первинної травми або в результаті вторинних системних розладів. 3. Для інтерпретації трансаміназемії необхідно враховувати не тільки сам факт збільшення, але й локалізацію та особливості поранення, ступінь збільшення амінотрансфераз, їх співвідношення та динаміку в посттравматичному періоді, що потребує подальшого вивчення.

Reactive hepatitis complicates the treatment of ballistic wounds. The aim of our study was to study the clinical and pharmacoeconomic effectiveness of the treatment of reactive hepatitis in the wounded. A prospective study of 112 wounded servicemen with increased transaminase activity was randomized into three groups: group I received arginine glutamate intravenously for 10 days, group II received phosphatidylcholine intravenously for 10 days, and group III received standard treatment. In the presence of hypoalbuminemia, the wounded received intravenous infusions of albumin to normalize its level in serum. The initial level of alanine aminotransferases was 62.5 in group I patients [50.5; 80.0] IU / l, in the second group - 64.0 [48.5; 83.0] IU / l and 62.0 [47.0; 85.5] IU / l, respectively, in group III (p> 0.05 according to the Mann-Whitney test). In the period up to 14 days after injury, alanine aminotransferase levels decreased significantly in all groups (p <0.05 according to Wilcoxon's test) and amounted to 38.5 in group I [34,0; 63.5] IU / l, in the second group 46.0 [32.0; 62.5] IU / l, in group III 50.0 [40.0; 78.0] IU / l (p = 0.014 according to the Mann-Whitney test compared to group I). In 14 and more days after injury in all groups the average concentration of alanine aminotransferases was significantly lower compared to the previous study period (p <0.05 according to Wilcoxon’s test): in group I the concentration of alanine aminotransferases was 33.0 [29,8; 40.0] IU / l (p = 0.048, p <0.001 according to the Mann-Whitney test in comparison with group II and III, respectively), in group II - up to 38.0 [31.0; 62.0] and in group III to 48.0 [39.5; 69.0] (p = 0.014 according to the Mann-Whitney test compared to group II). Also, there was a tendency to reduce the frequency of complications from internal organs: in 13% (8 of 63) patients of groups I and II, compared with 27% (13 of 49) of group III (p = 0.063). Significantly decreased both the duration of treatment in the intensive care unit: in group I (4.2 ± 1.8) days, compared with group III (7.4 ± 6.0) days, p = 0.012, and the duration of total hospital stay (20.4 ± 11.1) days for group I, compared with (29.7 ± 3.5) days for group III, p = 0.022. In the cost-effectiveness analysis of arginine glutamate and phosphatidylcholine regimens, a 2-fold better cost-effectiveness ratio was found in the group of reactive hepatitis wounded who received arginine glutamate.

Objective. The aim of the study was to improve the diagnosis of reactive hepatitis in injured with gunshot wounds. Methods. A retrospective analysis of 373 medical histories of servicemen wounded during the war in eastern Ukraine in 2014-2020, 233 of whom were hospitalized at the National Military Medical Clinical Center (NMMCC) and military medical clinical centres of the North, South, Eastern regions of the Ministry of Defense of Ukraine for more than 14 days. All servicemen had laboratory examinations using unified methods of laboratory tests. The obtained data were processed using non-parametric statistical methods. Results. The median baseline of ALT and, to a greater extent, AST (in the first period of traumatic illness) exceeds the upper limit of normal (40 IU / l). The highest values ​​of ALT were observed in the second period of traumatic illness on the 5th and 10th day of observation with a slight decrease in the next stage of the study. The concentration of AST increased significantly in the first period of traumatic illness, almost did not decrease in the second period, but approached normal values ​​≥14 days after injury. The strongest correlation between transaminases and albumin levels was found. A new calculated indicator in the form of the ratio of ALT concentration to albumin concentration (coefficient of reactive hepatitis of the injured, CRGI) is proposed. The development of post-traumatic reactive hepatitis was confirmed in all cases with the wounded with the value of CRGI ≥2.0. Conclusions. 1. Based on a retrospective analysis of 373 case histories of wounded in different periods after a gunshot wound, a new calculated indicator is proposed - the coefficient of reactive hepatitis of the injured (CRGI) in the form of the ratio of ALT/albumin concentrations, the increase of which indicates hepatocellular damage of hepatocytes with simultaneous suppression of the protein-synthetic function of the liver on the background of catabolic reactions. 2. CRGI ≥2 indicates the development of reactive hepatitis, is most often observed in the second period of traumatic illness and tends to normalize in the background of effective treatment. In the wounded who died as a result of injuries, CRGI steadily increased and was significantly higher than in the wounded with the uncomplicated course, especially in the third period of traumatic illness - after 14 days or more (4.0 vs. 2.3, respectively), which indicates the possible use of the proposed indicator as a prognostic criterion for worsening the prognosis in the wounded.

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