Journal of Clinical Practice

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The main idea of our journal is to provide description and analysis of clinical cases with severe, rare and difficult for diagnoses diseases, occurred in the clinics of Federal Medical-Biological Agency of Russia. Such clinical analysis is aimed to develop “clinical” type of thinking, always have been the characteristic feature of Russian/USSR medical school. The journal purpose is also to improve scientific discussions and cooperation between physicians of different specialties.

Revival of historical traditions in our journal is the one of the components of continuing education, which is especially important in “closed” territories, where doctors can`t regularly participate in clinical conferences. An important aspect is to provide a printed tribune for any doctor who has an interesting clinical observation and wish to share his experience with colleagues. That is why we named our journal "Clinical Practice" and address it, first of all, those skilled in applied medicine. Of course, we also publish the results of original researches, clinical guidelines, current reviews and medical news. The journal is multidisciplinary and we hope that it will be interesting to doctors of different specialties. The journal is published by means of the Federal Research and Clinical Center of FMBA of Russia. Placement of all materials, except for advertising, are free of charge to authors.

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Current Issue

Vol 12, No 2 (2021)

Original Research

ICU Acquired Weakness in patients with respiratory failure
Andreichenko S.A., Bychinin M.V., Korshunov D.I., Klypa T.V.
Abstract

Background: Most patients with severe respiratory failure in intensive care unit (ICU) require bed rest. The limitation of physical activity leads to some adverse consequences such as ICU Acquired Weakness (ICUAW). Progression of respiratory failure, including that caused by the new coronavirus infection (COVID-19), can lead to the development of acute respiratory distress syndrome, the treatment of which contributes to a combination of risk factors for the development of ICUAW. Traditional diagnostic methods have certain limitations. Muscle ultrasonography is a modern tool for early detection of muscle mass loss. Aims: To compare different methods of early ICUAW screening and to estimate the incidence and peculiarities of ICUAW in patients with respiratory failure of infectious genesis. Methods: 31 patients with severe coronavirus pneumonia (COVID-19 “+”) and 13 patients with viral and/or bacterial lung infection (COVID-19 “-”) were included in the study. The muscle mass loss percent from day 1 to day 7 was higher in the COVID-19 “-” group (p=0.022). These patients also had longer durations of the ICU and hospital stay but a significantly lower mortality (2.5 times). Results: The analysis of the parameters of deceased and living patients regardless of the lung damage etiology showed a correlation between the indices of hand grip strength dynamometry (handgrip test) and ultrasonography of the thigh muscles: F1 and D1 (rho=0.6, p=0.003), F1 and S1 (rho=0.6, p=0.005), D1 and F7 (rho=0.9, p=0.001). In addition, the examined levels of the ICUAW markers were associated with age - F1 (rho=-0.6, p=0.001), D1 (rho=-0.4, p=0.003), S1 (rho=-0.4, p=0.004). Conclusions: During the critical illness, ICUAW develops by the 3d day of bed rest in two thirds of patients with respiratory failure of different infectious genesis. The correlation between the investigated markers of ICUAW and age indicates that elderly patients are the most vulnerable category in respect to the formation and progression of muscle weakness in the ICU. The handgrip test can serve as a reliable and simple method of ICUAW screening. Early identification of patients with ICUAW should provide the improvement of nutritional support and individualization of rehabilitation.

Journal of Clinical Practice. 2021;12(2):5-13
pages 5-13 views
Development of a microfluidic biosensor for the diagnostics and typing of Mycobacterium Tuberculosis
Mitko T.V., Shakurov R.I., Shirshikov F.V., Svetlana S.V., Alieva E.V., Konopsky V.N., Basmanov D.V., Bespyatykh J.A.
Abstract

Background. Despite on the general trend towards decreasing the incidence of newly diagnosed active forms of tuberculosis, the situation with spreading of this disease in Russian Federation remains extremely tense. At the same time, the diagnosis is carried out according to the standard scheme, which takes about a month; another month takes test formulation for drug sensitivity. Thus, the development of new methods for diagnostics and typing of mycobacteria, as well as practice implementation of these developments is an urgent direction. Modern developments in the field of microfluidic technologies open up great opportunities in this direction. Aim. Development of a method for identification and typing of Mycobacterium tuberculosis using a label-free biosensor on surface waves in a one-dimensional photonic crystal (PC SM biosensor). Methods. Oligonucleotide probes were selected and synthesized as DNA targets for M. tuberculosis typing. The photonic crystal surface was modified with aqueous solutions of (3-aminopropyl)triethoxysilane, Leuconostoc mesenteroides dextrans and bovine serum albumin. Experiments were carried out using a PC SM biosensor. Results. Sequences of detecting oligonucleotide probes were selected for spoligotyping of M. tuberculosis on the PC SM biosensor. Modification of their 3'-ends was carried out in order to create extended single-stranded regions that are not subject to the formation of secondary structures and facilitate hybridization with a single-stranded DNA target. Several series of experimental modifications of the PC surface were carried out by using L. mesenteroides dextrans with different functional groups (including detection of the modification results real time) with simultaneous registration of the increment layer size and volume refractive index of the mixture, which excludes the use of a reference cell. Other experiments were carried out to detect the specific binding of biotinylated oligonucleotide probes to the modified PC surface. Conclusions. A technique for the design of probes was developed and a model system of oligonucleotides for the detection of single-stranded DNA using a PC biosensor was proposed. The developed technique of modification of the PC surface with dextrans from L. mesenteroides, which allows to increase the sensitivity of detection of oligonucleotides using the PC SM biosensor. This approach will further expand the panel of diagnostic probes, including identification of resistance markers.

Journal of Clinical Practice. 2021;12(2):14-20
pages 14-20 views
Biochemical and morphofunctional study of sperm of men infected with antibiotic-resistant strains of Ureaplasma urealyticum
Lutsky D.L., Lutskaya A.M., Vybornov S.V., Mahmudov R.M.
Abstract

Background: The role of UU in the pathogenesis of male infertility is currently not fully understood. Despite the widespread occurrence of antibiotic-resistant UU strains, there are virtually no data on their effect on the morphofunctional characteristics of the sperm and the biochemical parameters of the ejaculate. Aims: Comprehensive evaluation of the sperm fertility in men infected with antibiotic-resistant UU strains. Methods: The semen of men of active reproductive age (n=4752, age from 18 to 46 years, with the average age of 27.8±4.4 years) was studied. In the semen samples, UU was detected by the microbiological method (seeding on selective culture media with the subsequent identification and determination of the antibiotic sensitivity of the obtained isolates). The semen from men with mixed infections was excluded from the study. As a control, we used samples of ejaculates from healthy fertile men (n=67, age from 19 to 43 years, with the average age of 25.8±5.1 years). In the study of the ejaculate, the methods recommended by the WHO expert group were used. In addition to the standard spermogram, MAR tests (IgA, IgG and IgM) were performed, the degree of fragmentation of the sperm DNA was evaluated, the interaction of the sperm with hyaluronic acid was evaluated, as well, the activity of acrosine and neutral alpha-glucosidase was measured, the levels of zinc, citric acid, fructose and the level of glycodelin were determined. The study had been carried out between 2018 and 2021. Results: The most common resistance was to erythromycin (88.2%), less often — to azithromycin (47.0%), tetracycline (41.7%). The resistance to doxycycline (7.7%), josamycin (5.9%), and medicamycin (5.8%) was relatively rare. In men infected with antibiotic-resistant UU strains, the most frequently observed anomalies of a standard spermogram were those of the motor characteristics of spermatozoa — asthenozoo-spermia — and those of the spermatozoa's morphology — teratozoospermia. In the presence of polyresistant UU strains, a high degree of the sperm DNA fragmentation was more common (10.03% of cases) in respect to the cases of UU strains not resistant to antibiotics (5.92% of cases) or resistant to only one antibiotic (6.16% of cases). Abnormalities of the spermatozoa's interaction with hyaluronic acid were observed more often (more than 12% of cases) for antibiotic-resistant UU strains than for non-antibiotic-resistant UU strains (less than 4% of cases). In men infected with antibiotic-resistant UU strains, a decrease in the enzymatic activity of acrosin was often observed (29.71% of cases), most frequently among the cases with polyresistant strains (40.46% of cases). Conclusions: Antibiotic-resistant UU strains have a negative effect on the sperm fertility, of which the most pronounced negative effects are caused by polyresistant strains. We recommend measuring the acrosin activity when performing a spermogram for patients infected with UU. In the presence of polyresistant UU strains, it is advisable to assess the degree of the sperm DNA fragmentation. We recommend carrying out an antibioticogram before prescribing a treatment for ureaplasmosis.

Journal of Clinical Practice. 2021;12(2):21-29
pages 21-29 views
A mobile microfocal x-ray diagnostic complex in the imaging of premature newborns
Alkhazishvili A.V., Potrakhov Y.N., Misyurin A.S., Vodovatov A.V., Skripnik A.Y.
Abstract

Background: In the modern clinical practice, providing fast, mobile and high-quality bedside X-ray imaging is important for managing newborn children . Thus, the development of new devices with all these features and their clinical application are of considerable significance. Aims: Estimation of the diagnostic capabilities of a microfocal X-ray diagnostic complex for the imaging of premature newborns. Methods: The study was performed at the facilities of Almazov National Medical Research Centre. The study included X-ray examinations of 156 premature newborns using the method of microfocus radiography: 139 X-ray images of the chest, 17 X-ray images of the abdomen. The imaging was performed using the projection magnification technique with a patient positioned close to the X-ray source. Results: The microfocal X-ray images showed the necessary quality for the diagnosis of pathological changes in the chest and abdomen in infants. The patient dose estimation was based on the radiation output of the X-ray unit and the tube current-time product. For the maximum values of the tube voltage, tube current and exposure time, the effective doses did not exceed 0.02 mSv, corresponding to the “negligible” radiation risk category. Conclusions: Microfocal radiography allows performing informative X-ray examinations of premature newborns, especially using the projection magnification technique. The use of a microfocal X-ray diagnostic complex allows reducing patient doses, increasing the mobility and usability of the X-ray equipment. The first experience of clinical application of microfocal radiography in neonatology and pediatrics with the projection magnification of an X-ray image was found successful. The implementation of this device in pediatric clinical practice will optimize the tactics of managing premature newborns.

Journal of Clinical Practice. 2021;12(2):30-38
pages 30-38 views
Activity of free radical processes in oral fluid of patients with recurrent upper respiratory tract infections
Petrenko T.S., Novikova I.A., Denisova O.V., Devichenskiy V.M.
Abstract

Background: Upper respiratory tract infections occupy a leading position in the infectious pathology. According to the World Health Organization (WHO), up to 500 million people fall ill with acute respiratory infections in the world every year, of which 2 million people die from various complications. At the same time, a number of researchers note the lack of methods for clinical and laboratory assessment of the condition of patients with this pathology. Aims: To evaluate the parameters of free radical oxidation in oral fluid of patients with recurrent upper respiratory tract infections (RIURT). Methods: The study involved 64 apparently healthy people who suffered respiratory infections up to 2 times a year, and 85 patients with RIURT (4 or more times a year), who at the time of the study were in remission. The determination of the parameters of the pro / antioxidant systems was carried out using two methods (photometric: the content of lipid peroxidation products and the level of ceruloplasmin and luminol-dependent chemiluminescence (LDCL) were measured, making it possible to assess the complex interaction of two systems — prooxidants and antioxidants). Results: The studies have demonstrated that, for most of the RIURT patients during remission, the levels of certain prooxidant components (diene conjugates, ketodienes, Schiff bases), as well as of an oral fluid antioxidant (ADS: ceruloplasmin) were elevated compared to the controls. At the same time, the LDCL parameters of oral fluid did not go beyond the reference interval, although they were changed relative to the median of the control group. This allows us to consider the observed fluctuations as a balance in the system of pro- and antioxidants. Conclusions. The use of oral fluid as a biological material for the assessment of the pro-/antioxidant system opens up new possibilities in the diagnosis of respiratory disease.

Journal of Clinical Practice. 2021;12(2):39-46
pages 39-46 views
Objective and subjective assessment of the recurrence of atrial fibrillation after cryoballoon ablation of the pulmonary veins
Vachev S.A., Korolev S.V., Dupik N.V., Konev A.V., Zotov A.S., Khabazov R.I., Troitskiy A.V.
Abstract

Background: Adequate diagnosis of recurrent atrial fibrillation after the surgical treatment in patients with paroxysmal forms of the disease appears to be a difficult task. Aims: The manuscript is devoted to a comparative analysis of the results of subjective and objective assessment of atrial fibrillation recurrence after cryoballoon ablation of the pulmonary veins. Material and methods: 301 patients were included in the study. All of them consequentially underwent cryoballoon ablation of the pulmonary veins in the period of October, 2016 — November, 2019. The inclusion criteria were as follows: symptomatic atrial fibrillation; confirmation of atrial fibrillation by instrumental diagnostic methods. The exclusion criteria were the following: a combination of atrial fibrillation and atrial flutter at the time of surgery; history of open-heart procedures and catheter procedures to cease atrial fibrillation; the presence of concomitant cardiac and "arrhythmogenic" pathology. Results: In the period of May 01-30, 2020, 100% (n=301) of the patients included in the study were assessed by the method of targeted survey. The median duration of the postoperative period to the time of a patient's survey was 21 (3; 43) months. The interviews have shown that 136 (45%) patients noted a return of complaints associated with atrial fibrillation recurrence in the postoperative period. There was a clear tendency towards a decrease in the total number of patients with complaints of the clinical recurrence of the disease, depending on the time elapsed since the surgical procedure. The longer the period from the moment of surgery, the lower the number of patients with recurrence. Of 136 patients with recurrent complaints associated with atrial fibrillation, 97 (71%) were able to conduct the daily electrocardiogram monitoring. Of these, the instrumental recurrence of atrial fibrillation was confirmed in 59 patients, which amounted to 20% of all the patients included in the study (n=301). Conclusion: To establish the true number of atrial fibrillation recurrence after cryoballoon ablation of the pulmonary veins, a targeted survey of patients is desirable for up to 12 months after the surgery. The patients with complaints which suggest atrial fibrillation recurrence, even if these complaints do not correspond to the preoperative ones, should be invited for the instrumental diagnostics of arrhythmia.

Journal of Clinical Practice. 2021;12(2):47-53
pages 47-53 views
Ursodeoxycholic acid for the prevention of gallstone disease after bariatric surgery
Smirnov A.V., Ivanov Y.V., Stankevich V.R., Sharobaro V.I., Velichko E.A.
Abstract

Background: The development of gallstone disease (GSD) after bariatric surgery is a significant problem. The prophylactic effect of ursodeoxycholic acid (UDCA) preparations on the occurrence of cholelithiasis after gastric bypass and longitudinal gastrectomy has been studied. Aims: The aim of the study was to evaluate the effectiveness of ursodeoxycholic acid preparations in the prevention of cholelithiasis in patients after bariatric surgery. Methods: The results of a year-long follow-up for 128 patients after bariatric surgery were analyzed. In 68 patients, the prophylaxis of the gallstone disease development was not performed. 60 patients took a daily 500 mg dose of UDCA orally. Results: Cholelithiasis had developed in 17 (25%) patients who did not undergo the prophylaxis of cholelithiasis. Of these, 10 (14.7%) underwent cholecystectomy. Among those patients who took UDCA drugs, stones in the gallbladder were found in 7 (11.6%), and only one patient (1.7%) required a surgical treatment. Conclusion: UDCA administration during the first year after bariatric surgery in the amount of 500 mg per day significantly reduces the likelihood of the de novo cholelithiasis development. The medical prophylaxis of gallstone disease should be included in the standards of bariatric patients' management.

Journal of Clinical Practice. 2021;12(2):54-59
pages 54-59 views
Diagnostic imaging in patients with mucopolysaccharidosis: important imaging patterns
Yarmola I.I., Anikin A.V., Fomina L.E.
Abstract

Background: The need for systematization, generalization and analysis of structural changes in various organs and systems that occur in patients with mucopolysaccharidosis (MPS). MPS is a rare disease, therefore, there is a lack of structured information in Russian publications in the field of radiology. Aims: The purpose of the study is to summarize our own experience, identifying the incidence of changes in various organs and describing the most significant changes and their causes. Identification of more informative and safe diagnostic methods of various organs, taking into account the specificity of changes in MPS. Methods: Retrospectively, 303 children with MPS of different types were examined (the sample included 70 cases verified by the laboratory studies and molecular genetics), the revision of tomograms and radiographs was carried out for the studies from 2015 to 2021. All the patients underwent MRI of the brain and cervical spine, X-ray of the skeletal bones. Results: The analysis of the obtained images revealed the most common changes, such as dysostosis (in 100%; 70 patients), stenosis of the spinal canal at the craniovertebral level (73%; 51 patients), atrophy (47%; 33 patients) and focal lesions of the brain substance (67%; 47 patients), hydrocephalus (28%; 20 patients), expansion of the perivascular spaces (70%; 58 patients). The pathophysiological mechanisms of the occurrence of structural changes have been analyzed and described. Conclusions: The assessment and comparison of various diagnostic methods for different organs and systems has demonstrated that MRI is the most informative imaging method for the assessment of the craniovertebral junction. Given the lower radiation exposure compared to computed tomography, it is preferable to use digital radiography for examining the bones of the extremities.

Journal of Clinical Practice. 2021;12(2):60-68
pages 60-68 views

Reviews

Post-covid-19 neurological syndromes
Belopasov V.V., Zhuravleva E.N., Nugmanova N.P., Abdrashitova A.T.
Abstract

The article highlights the pathogenesis, clinical manifestations of lesions of the central and peripheral nervous system that have arisen or persist in patients in the postcoid period (Long-COVID-19). Their correct assessment, the use of effective methods of complex treatment, targeted neurorehabilitation contribute to the reversibility of functional disorders, prevention, reduction of disability, improvement of quality of life indicators, prevention of the progression of cognitive, emotional, behavioral disorders initiated by SARS-CoV-2.

Journal of Clinical Practice. 2021;12(2):69-82
pages 69-82 views
Pathogenesis of the initial stages of severe COVID-19
Golota A.S., Kamilova T.A., Shneider O.V., Vologzhanin D.A., Sherbak S.G.
Abstract

Since SARS-CoV-2 first appeared in humans, the scientific community has tried to gather as much information as possible in order to find effective strategies for the containment and treatment this pandemic coronavirus. We reviewed the current published literature on SARS-CoV-2 with an emphasis on the distribution of SARS-CoV-2 in tissues and body fluids, as well as data on the expression of its input receptors on the cell surface. COVID-19 affects many organ systems in many ways. These varied manifestations are associated with viral tropism and immune responses of the infected person, but the exact mechanisms are not yet fully understood. We emphasize the broad organotropism of SARS-CoV-2, as many studies have identified viral components (RNA, proteins) in many organs, including immune cells, pharynx, trachea, lungs, blood, heart, blood vessels, intestines, brain, kidneys, and male reproductive organs. Viral components are present in various body fluids, such as mucus, saliva, urine, cerebrospinal fluid, semen and breast milk. The main SARS-CoV-2 receptor, ACE2, is expressed at different levels in many tissues throughout the human body, but its expression levels do not always correspond to the detection of SARS-CoV-2, indicating a complex interaction between the virus and humans. We also highlight the role of the renin-angiotensin aldosterone system and its inhibitors in the context of COVID-19. In addition, SARS-CoV-2 has various strategies that are widely used in various tissues to evade innate antiviral immunity. Targeting immune evasion mediators of the virus can block its replication in COVID-19 patients. Together, these data shed light on the current understanding of the pathogenesis of SARS-CoV-2 and lay the groundwork for better diagnosis and treatment of patients with COVID-19.

Journal of Clinical Practice. 2021;12(2):83-102
pages 83-102 views
Modern approaches to the treatment of hallux rigidus
Airapetov G.A., Vorotnikov A.A.
Abstract

The number of patients with degenerative joint pathology is steadily increasing. Arthrosis of the 1st metatarsophalangeal joint (hallux rigidus) is no exception, it occurs in 20-35 % of young and working people who lead a mobile lifestyle and is manifested by a symptom complex, including pain and a significant restriction of the function of the entire lower limb. The leading cause of the pathology development is degenerative-dystrophic changes in the joint, leading to pain syndrome and restriction of movement. Today, there are a large number of treatment options, both conservative and surgical. The choice of a specific surgical intervention from the entire variety of options is a difficult task, it is strictly individual and requires consideration of various clinical manifestations of the disease and a number of other factors. So, if 10 years ago arthrodesis was considered a “gold standard” for the HR treatment, today most authors recommend organ-sparing treatment, in particular, shortening osteotomies of the metatarsal bone with a possible use of scaffolds for the regeneration of articular cartilage. The article analyzes the main results of the HR surgical treatment presented in the publications of national and foreign specialists. In some cases, our own recommendations on the choice of the method are suggested.

Journal of Clinical Practice. 2021;12(2):103-109
pages 103-109 views

Case report

Clinical case of Guillain-Barré syndrome associated with COVID-19
Shirshova E.V., Knaub V.V., Baklaushev V.P.
Abstract

Background: The coronavirus infection caused by SARS-Cov-2 is characterized by a damage to many organs and systems of the human body. To date, convincing information has been obtained about the involvement of various parts of the nervous system in the pathological process in patients with COVID-19. Among the most frequently described impairments, there are disorders of smell and taste, common disorders of the central nervous system, characterized by general cerebral symptoms, such as headache, asthenization, psychopathological disorders. One of the rare and severe forms of the peripheral nervous system damage in COVID-19 is Guillain-Barre syndrome (GBS), characterized by acute post-infectious inflammatory polyneuropathy with an autoimmune etiology. Clinical case description. We present a clinical case of GBS associated with COVID-19. The disease debuted as a peripheral tetraparesis with a progredient course of up to 21 days. Systemic administration of immunoglobulin stopped the disease progression. The association of GBS with COVID-19 was clarified a month after the disease onset, when bilateral polysegmental pneumonia was diagnosed, and a high level of IgG to the S-protein of SARS-CoV-2 was found, 3 times higher than the level of IgM, which indicated the duration of the disease was not less than three weeks. Conclusion: The GBS development upon infection with SARS-CoV-2 may precede the lung damage. The debut of GBS during the COVID-19 pandemic requires the exclusion of the SARS-CoV-2 etiological role in each case.

Journal of Clinical Practice. 2021;12(2):110-118
pages 110-118 views

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