Journal of Clinical Practice

Dear Colleagues!

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 11, No 4 (2020)

Оригинальные исследования
Five-year result of Microvascular decompression using video endoscopy in the treatment of classic trigeminal neuralgia with paroxysmal pain syndrome
Vinokurov A.G., Kalinkin A.A., Bocharov A.А., Kalinkina O.N.

Background. The incidence of trigeminal neuralgia (TN) is 15 per 100,000 people per year. The effectiveness of the existing conservative methods of therapy does not exceed 50%. At the same time, the use of carbamazepine doubles the frequency of depressive conditions, and by 40% increases the incidence of suicidal thoughts. Microvascular decompression (MVD) of the trigeminal root is a"gold standard" treatment for patients with facial pain, however, due to the lack of awareness of the disease, not all the patients receive the adequate therapy timely. Aims: to evaluate the long-term results of video endoscopy-assisted microvascular decompression in the treatment of patients with classical trigeminal neuralgia (cNTN) with paroxysmal facial pain. Methods. In the period from 2014 to 2019, 62 patients were operated for classic NTN and paroxysmal facial pain. The average period from the onset of pain syndrome to surgery was 5 years (from 2 months to 15 years). All the patients in the preoperative period underwent conservative therapy (carbamazepine, gabapentin, pregabalin), which was not accompanied by significant pain reduction. Two (3%) patients had previously undergone a radiosurgical treatment using the Gamma Knife device, and 7 (11%) patients had an analgesic blockade without an effect at other hospitals. The maximum pain intensity upon the admission to the hospital, according to the visual analogue scale (VAS,) was 10 points, according to the BNI (Barrow Neurological Institute) pain syndrome scale — V. All the patients underwent MVD of the trigeminal nerve root using Teflon, and video endoscopic assistance during surgery was used in 9 patients . The average follow-up period after the surgery was 3.4 ± 1.7 years (from 1 to 5 years). Results. In all (100%) the patients, the pain was completely relieved after the surgery (BNI I). Excellent and good results after MVD within 5 years were achieved in 97% of patients (BNI I–II). Facial hypesthesia, not causing discomfort and anxiety (BNI II), developed in 5 (8.1%) patients. The use of video endoscopy made it possible to identify the vessels compressing the trigeminal nerve root with a minimal traction of the cerebellum and cranial nerves. The development of cerebellar edema and ischemia occurred in one (1.6%) patient operated without the application of video endoscopy. Conclusion. The MVD method with video endoscopy is effective in the treatment of patients with cNTN with paroxysmal pain syndrome.

Journal of Clinical Practice. 2020;11(4):5-13
The experience with the use of a subacromial balloon in the treatment of patients with large, massive, irreparable rotator cuff tears
Lazko М.F., Prizov A.P., Lazko F.L., Beliak E.A., Maglaperidze I.G., Kyznetsov A.V., Akhpashev A.A.

Background. Large, massive irreparable rotator cuff tears lead to a significant decrease in the function of the shoulder joint together with the development of a pronounced pain syndrome. Such injuries are difficult to treat, and the number of relapses, when trying to restore them, is quite high. The installation of a subacromial balloon is the method of choice for this group of patients and allows restoring the function of the shoulder joint fairly successfully. Aim: to evaluate the results of the treatment of patients with massive irreparable rotator cuff tears injuries in a prospective study from 2016 to 2018. Methods. The results of the arthroscopic treatment of large, irreparable rotator cuff injuries in 25 patients (with the average age of 67 ± 5 years) with the installation of a subacromial balloon are presented. In all the clinical cases, there was a pronounced (grades 3–4, according to the Goutallier classification) fatty dystrophy of the rotator cuff muscles (supraspinatus or in combination with subaspinatus). All the patients underwent the subacromial space release with a thorough bursectomy and subsequent installation of a subacromial balloon. Results. The average score on the UCLA scale was 14 ± 3 points (11–17) before the operation and 31±2 points (29–33) 12 months after the operation, the results were considered good and excellent. Conclusion. The results obtained allow us to evaluate the described technique as low-traumatic, simple and fast in its accomplishment, aimed at the reduction of the pain syndrome and restoration of the upper extremity function.

Journal of Clinical Practice. 2020;11(4):14-22
Prevalence of obesity in women of different ages and its relationship with arterial stiffness
Ivanova O.S., Maychuk E.Y., Voevodina I.V., Orlov A.V.

Background. General and abdominal obesity is widespread among women in the Russian population. The relationship between obesity and arterial stiffness, as a predictor of the development of cardiovascular diseases, in women of different ages remains unclear. Aims: to study the relationship between obesity and arterial stiffness and dynamics of central aortic pressure in women of different ages with preserved and lost reproductive function. Methods. 161 women were examined and divided into 3 groups. Two groups included women with preserved reproductive function: group 1 consisted of 52 young women aged from 18 to 30 years (23.8 ± 5.3 years); group 2 included 54 women aged from 31 years to the menopause (41 ± 5.9 years). Group 3 included 55 postmenopausal women (55.4 ± 5.8 years). All the women underwent a clinical examination with anthropometry; questioning; 24-hour monitoring of the dynamics of blood pressure with measuring the indicators of arterial stiffness and daily aortic central pressure; determination of the carotid-femoral pulse wave velocity (cfPWV); study of vascular stiffness by volume sphygmography. Results. The anthropometric data in groups 2 and 3 were comparable in terms of the prevalence of general obesity (GO). Abdominal obesity (AO) was detected in 19.2% of the 1st group; 51.9% of the 2nd and 76.4% of the 3rd group. In the 1st group AO had the strongest correlation with the aortic pulse wave velocity PWVao (R = 0.41, p = 0.002) and the corrected to HR75 augmentation index Aixao (R = 0.38, p = 0.005). In the 2nd group AO correlates with cfPWV (R = 0.4, p = 0.003); GO with PWVao (R = 0.38, p = 0.005) and aortic cardio-ankle vascular index CAVIao (R = 0.48, p = 0.001). In the 2nd group AO and GO are also interconnected with the central and peripheral pressure. In the 3rd group AO correlates with PWVao (R = 0.33, p = 0.01), cfPWV (R = 0.32, p = 0.02); GO with the index of the double product IDP (R = 0.36, p = 0.01). Conclusions. Obesity, especially its abdominal type, is an important factor determining the development of vascular wall stiffness in women of the reproductive age. It is necessary to conduct a comprehensive assessment of arterial stiffness and daily dynamics of central aortic pressure in women of all ages, suffering from obesity and, first of all, its abdominal type, in order to early diagnose subclinical changes in the vascular wall and central hemodynamic disorders.

Journal of Clinical Practice. 2020;11(4):23-30
Application of external osteosynthesis in correction of varus deformation of lower extremities in patients with gonarthrosis
Artemiev A.A., Akhpashev A.A., Abakirov M.D., Reshetnikov A.N., Shipulin A.A., Gululyan G.G., Kashoob A.M., Solovyov Y.S.

Background. Arthrosis of the knee joint is one of the most common diseases in elderly patients with the varus deformity. One of the treatment methods is corrective osteotomy. Aims: optimization of the diagnosis of deformities in patients with gonarthrosis, improvement of the technique of operation and postoperative control of the main reference lines and angles, assessment of the correction results, analysis of complications. Methods. A retrospective clinical study was conducted. 39 patients were observed, in whom 78 operations were performed on both legs simultaneously. In all the cases, tibia osteotomies and osteosynthesis with the Ilizarov apparatus were used. All the patients underwent an X-ray study of the legs along the entire length with the identification of the main reference lines and angles. Results. In all the cases, it was possible to normalize the position of the mechanical axis and the angle of orientation of the knee joint. After the surgery, the wounds were not sutured to prevent compartment syndrome. The correction was performed in a single-stage manner in elderly patients, gradually in young patients. The period of fixation with the Ilizarov apparatus was 16.6 ± 3.1 weeks. Conclusions. The Ilizarov method has significant advantages: low invasiveness, stable fixation, absence of foreign bodies to the end of treatment. This allows us to recommend it for a wider use in patients with gonarthrosis and varus deformity.

Journal of Clinical Practice. 2020;11(4):31-40
Influence of the anterior chamber depth on the accuracy of the intraocular lens optical power calculation in short eyes
Tsygankov A.Y., Pershin K.B., Pashinova N.F., Likh I.A., Akhrarov A.A.

Background. The calculation of the optical strength of the intraocular lens (IOL) in eyes with a short anterior-posterior axis presents significant difficulties due to non-standard anatomical parameters of the eye, including the anterior chamber depth. Aim: determination of the relationship between the anterior chamber depth (ACD) and the accuracy of the IOL optical power calculation in eyes with an axial length of less than 22 mm. Methods. A total of 86 patients (133 eyes) with a short axis — from 18.54 to 21.98 (20.7 ± 0.9) mm, were included in the study. Group I (n = 29, 40 eyes) consisted of patients with ACD of less than 2.5 mm. Group II (n = 30, 49 eyes) included patients with ACD from 2.5 to 2.9 mm Group III (n = 27, 44 eyes) included patients with ACD greater than 2.9 mm. The calculation of the IOL optical power was carried out according to the formula SRK/T, the retrospective comparison was performed according to the Hoffer Q, Holladay II, Olsen, Haigis and Barrett Universal II formulas. Results. In all three groups, there was an increase in UCVA and BCVA in the postoperative period. In group I, there were no significant differences when comparing MedAE for the six formulas (p < 0.05). The highest MedAE values (0.51 and 0.49 respectively) and the smaller MNE range (-0.03 ± 0.89 and -0.01 ± 0.97 respectively) are shown for the Haigis and Barrett Universal II formulas. In group II, the MedAE for the Haigis formula was 0.45, for SRK/T and Olsen it was 0.59 and 0.66. For the Haigis formula, the lowest MNE value (0.05 ± 0.69) is shown. In group III, no significant differences were found when comparing the average values of MedAE (р > 0.05). The lowest MedAE (0.17) and the best MNE values (-0.01 ± 0.58) are shown for the Haigis formula, while the SRK/T formula was characterized by the highest MedAE (0.37). In group II, the refractive index ±0.25 and ±0.50 D for the Haigis formula was significantly higher. Conclusion. For eyes with ACD of less than 2.4 mm, none of the formulas showed a significant advantage, while for ACD of 2.4–2.9 mm and higher, the use of the Haigis formula is recommended, and the SRK / T formula showed the worst result. The data obtained dictate the need to review the existing standards for calculating the IOL optical power in patients with short eyes depending on ACD.

Journal of Clinical Practice. 2020;11(4):41-48
The influence of model iterative reconstruction on the image quality in standard and low-dose computer tomography of the chest. Experimental study
Silin А.Y., Gruzdev I.S., Morozov S.P.

Background. One of the ways to reduce the radiation dose in CT is to the image reconstruction algorithms. The latest offer from CT scanner manufacturers is Model Iterative Reconstruction (MIR). Aims: to compare the quality of visualization of the structures of the chest organs and to prove the effectiveness of the low-dose protocol with iterative model reconstruction. Methods. A calibration phantom with a spatial resolution module and an anthropomorphic phantom of the upper body of an adult with nodules in the lungs were scanned using two CT scanners of different manufacturers. Two protocols were applied: the standard dose protocol (SDCT) with the algorithms of hybrid iterative reconstruction (HIR) of images and MIR and a low-dose protocol (LDCT) with the MIRalgorithm. The quality of the obtained images was evaluated by the following parameters: noise (SD), the contrast-to-noise ratio (CNR), spatial resolution and visualization of pulmonary nodules. The radiation dose was calculated according to the scanner data, the data of individual dosimeters placed on the anthropomorphic phantom, and using a dosimetric phantom. Results. The average SD was 11.5; 24.4 and 21.6; CNR 85.47; 40.6 and 45.6; spatial resolution 2 mm; 2 mm and 3 mm for SDCT with MIR, SDCT with HIR and LDCT with MIR respectively. Visualization of the pulmonary lesions remained excellent in all cases. The radiation dose in case of SDCT was 2.7, and in case of LDCT — 0.67 mSv. The dose reduction was confirmed by the dosimeter data. Similar results were obtained by repeating the experiment with a second scanner. Conclusions. The model iterative reconstruction application will allow reducing the irradiatin dose during CT scanning of the chest organs without deterioration of the visualization quality.

Journal of Clinical Practice. 2020;11(4):49-54
Simultaneous surgeries in bariatric surgery (literature review)
Smirnov A.V., Stankevich V.R., Panchenkov D.N., Sharobaro V.I., Ivanov Y.V., Velichko Y.A.

Based on the available publications, the article presents an analysis of the studies on the simultaneous implementation of cholecystectomy, ventral and paraesophageal hernia repair during a bariatric intervention. If there is a clinical picture of chronic calculous cholecystitis, simultaneous cholecystectomy is justified and does not lead to a significant increase in the number of complications. In the case of asymptomatic gallstones, the optimal tactics remains controversial, both a surgical treatment and observation are possible. In the absence of gallstone disease, all patients after the surgical correction of the excess weight are prescribed ursodeoxycholic acid, while performing preventive cholecystectomy is not recommended. A simultaneous ventral hernia repair is justified only for small defects (< 10 cm) of the anterior abdominal wall. If a paraesophageal hernia is detected in patients with morbid obesity, bariatric surgery may be combined with cruroraphy.

Journal of Clinical Practice. 2020;11(4):55-63
Diagnosis and treatment of iliac vein stenosis
Gitelzon D.G., Faybushevich A.G., Maximkin D.A., Veretnik G.I., Baranovich V.Y., Gitelzon E.А., Sabirov K.R., Vasilyev A.E., Danishian K.I.

Stenosis of the iliac veins is common in patients with chronic venous insufficiency. The article describes the methods for the diagnosis and treatment of iliac vein stenosis. The causes of iliac vein stenosis include extravasal compression or the consequences of ileofemoral thrombosis. Stenosis of the iliac veins exists in 1/4 of the entire adult population, but clinical manifestations do not occur in all patients. Stenosis of the iliac veins should be considered in case of an unknown edema, more often in the left lower extremity, since venous duplex ultrasound of lower extremities is not sensitive and specific enough when examining the veins above the inguinal ligament. The most accurate diagnostic method is intravascular ultrasound (IVUS) but the appeared computed tomography angiography (CTA) and magnetic resonance angiography (MRA) with high-quality images have become a good replacement for IVUS. The main method of treatment of iliac vein stenosis, besides stenting, isindispensable drug therapy consisting of antithrombotic and phlebotonic drugs.

Journal of Clinical Practice. 2020;11(4):64-69
Biomarkers of acute myocardial infarction: diagnostic and prognostic value. Part 2 (Literature review)
Chaulin A.M., Duplyakov D.V.

In the second part of the review, we continue the discussion of biomarkers that have a diagnostic and prognostic significance in acute myocardial infarction (AMI). The study of the AMI pathophysiology through the experimental and clinical research contributes to the discovery of new regulatory molecules and pathogenetic mechanisms underlying AMI. At the same time, many molecules involved in the pathogenesis of AMI can be used as effective biomarkers for the diagnosis and prediction of AMI. This article discusses in detail the diagnostic and prognostic value of inflammatory biomarkers of AMI (C-reactive protein, interleukin-6, tumor necrosis factor-alpha, myeloperoxidase, matrix metalloproteinases, soluble form of CD40 ligand, procalcitonin, placental growth factor) and a number of recently discovered new biomarkers of AMI (microribonucleic acids, galectin-3, stimulating growth factor expressed by gene 2, growth differentiation factor 15, proprotein convertase of subtilisin-kexin type 9).

Journal of Clinical Practice. 2020;11(4):70-82
Описание клинических случаев
Rapidly progressive course of nonspecific aortoarteritis: a clinical case
Grushina M.V., Grekov I.S., Arkhypova K.D.

Background. Nonspecific aortoarteritis, or Takayasu’s disease, is one of the most complex and rare pathologies in modern clinical practice. It is the orphan nature of the disease, along with non-specific clinical manifestations, that causes a large number of clinical and diagnostic errors that lead to an unfavorable prognosis and early disability of patients. Despite the development of modern methods of treatment of nonspecific aortoarteritis, in some cases it is not possible to achieve a stable remission, which leads to a steady progression of the pathological process. Clinical case description. The article presents a case of a rapidly progressing course of Takayasu's disease in a young woman with multiple arterial vascular lesions that developed during the first year after the onset of arterial hypertension, while the narrowing of the carotid arteries (75–85%) was not accompanied by signs of cerebral ischemia. The follow-up period was 10 years. Conclusion. Given the peculiarities of this nosology, each identified case of Takayasu’s disease is of great clinical and practical interest. The disease peculiarity in thise patient is that during the first year from the onset of arterial hypertension, the main occlusive lesions of the aorta and arterial vessels were identified. At the same time, the narrowing of the carotid arteries (75–85%) was not accompanied by signs of cerebral ischemia. It should be noted that often the symptoms of non-specific aortoarteritis appear under the “masks” of other diseases, which requires a careful differential search. A correct diagnosis and timely treatment can prevent the development of complications and slow the progression of the disease.

Journal of Clinical Practice. 2020;11(4):83-89
Delayed sinus rhythm restoration after thoracoscopic left atrium fragmentation (а report of two cases)
Vachev S.A., Korolev S.V., Zotov A.S., Khabazov R.I., Troitskiy A.V.

The article presents two clinical cases of delayed restoration of the sinus rhythm in patients with long-term persistent atrial fibrillation after the procedure of thoracoscopic radiofrequency fragmentation of the left atrium. The necessity of continuing attempts to restore the sinus rhythm up to the end of the "blind period" (90 days) is discussed.

Journal of Clinical Practice. 2020;11(4):90-95

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