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 13, No 2 (2022)

Original Research

Shortening of the PR interval in pericarditis after coronary bypass surgery
Dundua D.P., Khabazov R.R., Hricheva N.A.
Abstract

Background: Pericarditis, following pericardiotomy, is a well-known complication of cardiac surgery. The diagnosis of postpericardiotomy pericarditis (PP) is based on the electrocardiography (ECG) changes — the ST segment elevation in combination with a depression of the PR interval. However, in some cases, the ECG changes are difficult to distinguish from the changes associated with ST segment elevation acute coronary syndrome. In such cases, the diagnosis of pericarditis is made by excluding acute coronary syndrome, for which additional expensive diagnostic tests are performed. Aims: the purpose of the study is to identify a pattern in the change in the PR interval, which is detected in patients with acute pericarditis who underwent pericardiotomy during coronary bypass surgery. Methods: The observational study included 47 patients after coronary bypass surgery. We compared ECG of two groups of patients after coronary artery bypass grafting — 25 patients who demonstrated the ECG signs of acute pericarditis and 22 patients without those. Results: In most patients with PP after coronary bypass surgery, the characteristic ECG signs of acute pericarditis were accompanied by a transient shortening of the PR interval by 0.04 sec. Conclusion: The absence of such dynamics in patients after coronary artery bypass grafting without the ECG signs of pericarditis may indicate that a transient shortening of the PR interval may be an additional easily available ECG sign of acute PP.

Journal of Clinical Practice. 2022;13(2):5-11
pages 5-11 views
A preliminary analysis of a prospective multicenter randomized controlled study of the efficacy and safety on traditional and distal radial access in interventional cardiology
Kartashov D.S., Babunashvili A.M., Shumakov D.V., Korotkikh A.V., Kaledin A.L., Derkach V.V., Portnov R.M., Ahramovich R.V., Zulkarnaev A.B.
Abstract

Background: Despite the obvious advantages of transradial access and its widespread use, there are technical problems that force interventional surgeons to improve the methods of endovascular interventions. Aims: to analyze the effectiveness and safety of distal and traditional radial access for endovascular interventions. Methods: The study included 282 patients who underwent an endovascular intervention with distal radial access (DRA, 139 patients) or traditional radial access (TRA, 143 patients). The study is registered at www.clinicaltrials.gov, NCT04211584. Results: The median diameter of the radial artery in its proximal part, i.e. at the site of TRA, was 2.5 mm [Q1; Q3: 2.27; 2.8], in the DRA group the median was 2.28 mm [Q1; Q3: 2.06; 3.56], p <0.0001. We noted statistically significant differences in the duration of puncture (p=0.0215), but not in the duration of the introducer insertion, catheterization of the coronary artery, fluoroscopy, the total time of intervention, the dose of ionizing radiation. In total, 28 complications developed (9.9% of 282): 14 in each of the groups in one year after the intervention. Two (0.7% of 282) patients developed bleeding [1 (0.7% of 139) — DRA, 1 (0.7% of 143) — TRA], 5 (1.8% of 282) — radial artery dissection [2 (1.4% of 139) — DRA, 3 (2.1% of 143) — TRA], 9 (3.2% of 282) — puncture failure [7 (5% of 139) — DRA, 2 (1.4% of 143) — TRA], 4 (1.4% of 282) — radial artery perforation [2 (1.4% of 139) — DRA, 2 (1.4% of 143) — TRA], 7 (2.5% of 282) — hematoma more than 5 cm [2 (1.4% of 139) — DRA, 5 (3.5% of 143) — TRA], 1 (0.4% of 282) — radial artery thrombosis [(0.7% of 143) TRA]. The risk of complications did not depend on the type of access. Conclusions: Distal and traditional radial access do not differ in their efficiency and safety. At the same time, we noted a certain tendency to a longer puncture of the radial artery with distal radial access compared to the traditional one, which is due to the smaller diameter of the radial artery.

Journal of Clinical Practice. 2022;13(2):12-19
pages 12-19 views
Induced blood oxidation in myocardial revascularization
Shereshneva M.V., Ilyin M.V., Sandugey A.V., Zotov A.S.
Abstract

Background: The use of artificial circulation in surgical myocardial revascularization is one of the key pathogenetic factors in the development of the oxidative stress and systemic inflammatory response in the postoperative period. Aims: the purpose of the study was to describe the dynamics of the induced blood oxidation parameters during coronary artery bypass surgery in the conditions of artificial circulation and on the working heart. Methods: The study included 64 patients who underwent coronary bypass surgery, with 31 (48.4%) on-pump patients and 33 (51.6%) off-pump patients. The oxidative stress simulations were conducted under the in vitro conditions. The blood oxidation-induced values were studied using a biological oxygen monitor. Results: In patients with coronary heart disease, regardless of the choice of the revascularization method (on-pump / off-pump), we observed statistically significantly (p <0.05) higher initial and maximum blood oxidation rates, the oxidative activity factor, and a shorter initiation period than those in healthy volunteers. No significant differences were found by the inter-group comparison analysis both 10 days and 6 months post-surgery. Conclusion: The indicators of induced blood oxidation do not depend on the method of revascularization during coronary bypass grafting (artificial circulation or a working heart). The changes in the parameters indicating activation of the oxidative and antioxidant blood systems may be transient by their nature and occur in the early postoperative period.

Journal of Clinical Practice. 2022;13(2):20-28
pages 20-28 views
Association of the quality of life parameters with the indicators of chronic heart failure severity in patients with rheumatoid arthritis
Ankudinov A.S., Kalyagin A.N.
Abstract

Background: The quality of life of patients is one of determining factors in assessing the effectiveness of treatment and prognosis. A search for possible associations of the quality of life parameters with basic clinical indicators provides a possibility of a more detailed and comprehensive assessment of the patient’s condition, correction of therapy and an improvement in the prognosis. Aim: To carry out a comparative analysis of the quality of life parameters in patients with chronic heart failure (CHF) with preserved and moderately reduced left ventricular ejection fraction against the background of rheumatoid arthritis (RA) and without RA, as well as to identify possible associations of the quality of life indicators with the parameters of the CHF course. Methods: 134 CHF patients with an RA diagnosis were examined, as well as 122 CHF patients without RA. The functional class of CHF in patients participated in the study was I -II by NYHA. The diagnosis of RA was made on the basis of radiological and serological studies. The radiological stage of RA in patients included in the study was I -III, according to Steinbrocker. Methotrexate was the basic anti-inflammatory drug for the RA treatment. A comparative analysis of the CHF symptoms, morphofunctional parameters and their possible association with the quality of life indicators in patients with and without RA was performed. The processing was carried out using the Statistica 10.0 program. Results: In the group of patients with CHF and RA, in addition to the statistically significant differences in the standard clinical laboratory parameters, statistically significant differences were also revealed in the severity of pain syndrome, deterioration of role, physical and emotional functioning as compared to the CHF patients without RA. Besides, in the CHF/RA group, statistically significant associations were revealed between the severity of pain syndrome and the level of the left ventricular ejection fraction and left ventricular mass index. Conclusion: The severity of pain syndrome caused by RA in patients with CHF can negatively affect some morphological and functional parameters of the myocardium, which must be taken into account when managing this group of patients.

Journal of Clinical Practice. 2022;13(2):29-36
pages 29-36 views
Affective disorders and сognitive impairment in the early stages of Parkinson’s disease
Makhmudova G. ., Vellovich N.I., Shirshova E.V.
Abstract
Background: Parkinson's disease (PD) is an age-related neurodegenerative disease in developed countries. The prevalence of PD ranges from 41 per 100,000 in the fourth decade of life to more than 1,900 per 100,000 in people over 80 years of age. Neurodegeneration associated with Parkinson's disease probably occurs several decades before the onset of motor symptoms. Affective and cognitive impairments are one of the most frequent non-motor manifestations of PD, which can lead to a number of adverse outcomes. Aim: to evaluate affective and cognitive impairments in patients at the early stages of PD. Methods: 61 patients with PD participated in the study. All the participants were divided into two groups depending on the presence or absence of a diagnosis of depression verified by psychiatrists: Group 1 was the main group (n=48), group 2 was the control group (n=13). The control group included patients without depression. The average age of the participants was 62.2±9.6 years. The analysis of the PD stages was carried out in both groups. In the main group, stage II PD was diagnosed in 75%, in the control group — in 31% of patients. The average duration of the disease was 2.5±1.6 years. A clinical examination was carried out using the Beck depression questionnaire, apathy scale, Spielberger anxiety questionnaire and anxiety assessment scale in PD (to assess emotional disorders), cognitive function assessment scale in PD (SHOBP-Cog, Scopa-Cog), digital symbol replacement test (symbols-numbers test), Montreal assessment Scale cognitive functions (MoCA test), a test for connecting numbers and letters, and a Stroop test (for evaluating cognitive functions). Results: It was revealed that in the early stages of PD, the prevalence of depression, clinically significant apathy, personal and reactive anxiety was high. Significantly higher rates of depression severity, depression level, apathy level and personal anxiety were noted among the patients with stage II PD compared to the patients with stage I PD. There was a marked tendency to a decrease in cognitive functions at stage I of PD, aggravated at stage II of the disease, which was confirmed by the results of the tests: a low level of cognitive functions on the Montreal scale was detected in 52%; 70% of patients, regardless of the PD stage, showed a low rate of completion of the 1st and 2nd parts of the Stroop test for their age; the results of the digital character replacement test were below normal in 75% of cases. Conclusion: The most common affective disorders in the early stages of PD are depression and anxiety. Apathy and depression have a negative impact on the cognitive functions of patients, which worsen with the progression of the disease.
Journal of Clinical Practice. 2022;13(2):37-44
pages 37-44 views
Biomechanical properties of the cornea in Floppy eyelid syndrome
Krinitsyna E.A., Grusha Y.O.
Abstract

Background: Floppy eyelid syndrome (FES) is a frequently underdiagnosed disorder of unknown pathogenesis. FES has been associated with ocular conditions such as keratoconus. At present, despite the frequent combination of FES and keratoconus, there are almost no data on the biomechanical properties of the cornea in these patients. Aims: to determine the cornea’s biomechanical properties in patients with floppy eyelid syndrome. Methods: The study included 40 patients (54 eyes) with hyper-extensible eyelid syndrome. The average age was 53.9±6.7 years. The central corneal thickness averaged 551±25 µm. All the patients underwent a standard ophthalmological examination, including pneumotonometry. The intraocular pressure (IOP) and biomechanical properties of the cornea were measured using dynamic bidirectional applanation. Results: The study of the cornea’s biomechanical properties in patients with floppy eyelid syndrome showed a decrease in the corneal hysteresis (CH) indices to 9.96±0.61 mm Hg on the average, in the corneal resistance factor (CRF) — to 9.54±0.64 mm Hg. Moreover, their value varied depending on the severity of the syndrome. The mean value of the corneal compensated IOP (IOPcc) in the entire sample was 15.5±1.0 mm Hg, Goldman IOP (IOPg) — 15.1±2.0 mm Hg, pneumotonometric IOP — 11.61±2.9 mm Hg. Regardless of the severity, the pneumotonometric IOP indices did not have statistically significant differences, while as this syndrome progressed, the IOPcc and IOPg indices showed a steady decrease in the mean values. Conclusions: It was found that, in floppy eyelid syndrome, the biomechanical parameters of the cornea were reduced. At the same time, the value of these indicators varied significantly with the severity. The largest and the smallest decrease were observed in the corneal hysteresis index and the corneal-compensated IOP, respectively.

Journal of Clinical Practice. 2022;13(2):45-50
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Eхperience of endoscopic decompression of the suprascapular nerve
Belyak E.A., Pashin D.L., Lazko F.L., Prizov A.P., Lazko M.F., Zagorodniy N.V., Asratyan S.A.
Abstract

Background: Suprascapular nerve neuropathy is a commonly spread pathology, caused by a traction force trauma or compression in the scapular notch area. In the case of a conservative treatment failure, a standard surgical procedure is neurolysis (decompression) of the suprascapular nerve in the scapular notch. This procedure can be done in an open manner or endoscopically. Aims: to evaluate the results of endoscopic decompression of the suprascapular nerve in the scapular notch area at a 6 months follow-up. Methods: We operated 10 patients with the clinical picture of posttraumatic suprascapular nerve neuropathy in the period from 2015 to 2021. The mean age of patients was 52.3±11.8. All the patients underwent the shoulder joint and subacromial space arthroscopy, and decompression of the suprascapular nerve in the scapular notch area. Results: According to the VAS-scale, the severity of pain syndrome before the surgery was 6 cm, while in 6 months after the surgery it decreased to 2 cm. According to the DASH scale, the dysfunction of the of shoulder joint before the surgery was 70 points, in 6 months after the surgery it decreased to 10 points. The range of motion in the shoulder joint before the surgery was: flexion 155±14,4°, abduction 140±42°, external rotation 12±5,6°; 6 months after the surgery we observed: flexion 174±15,6°, abduction 175±14,4°, external rotation 48±9°. Conclusion: The obtained results let us characterize the method of endoscopic decompression of the suprascapular nerve as a low-traumatic and effective technique, which promotes restoration of the function of the suprascapular nerve and shoulder joint, and elimination of pain syndrome from the shoulder area.

Journal of Clinical Practice. 2022;13(2):51-58
pages 51-58 views
X-ray-endovascular interventions in the treatment of patients with liver metastases of colorectal cancer after the termination of systemic chemotherapy
Stukalova O.Y., Polikarpov A.A., Ishchenko R.V., Shugushev Z.K.
Abstract

Background: At present, the problem of treating common forms of colorectal cancer does not lose its relevance due to the increase in its incidence. Systemic chemotherapy is the main line of treatment for patients with unresectable liver metastases. However, a significant problem of modern oncology is the further treatment tactics for patients with chemoresistant metastases. Aims: to improve the treatment results for patients with chemoresistant liver metastases of colorectal cancer. Method: 36 patients with unresectable liver metastases of colorectal cancer were treated at the Granov Russian Research Center of Radiology and Surgical Technologies and the «RZD-Medicine» Central Clinical Hospital. For all the patients, systemic chemotherapy was considered unreasonable due to the development of chemoresistance or a high degree of toxicity. The patients underwent regional chemotherapy — chemoinfusion and/or chemoembolization of the hepatic artery. Results: The treatment evaluation was performed using the RECIST 1.1 scale. After 6 months, a partial response was reached in 1 patient (2.8%), stabilization was observed in 29 (80.5%) patients, and 6 patients (16.7%) had the disease progression. In 2 (5.6%) cases, a lethal outcome was observed against the background of the systemic progression of the oncological disease. One year later, stabilization of the malignant process was detected in 21 (58.3%) cases, progression was detected in 15 (41.7%) cases. A one-year survival of patients was 83.3%, the overall survival — 22 months. Conclusion: The use of interventional radiology methods has shown its effectiveness in patients with unresectable chemoresistant liver metastases of colorectal cancer.

Journal of Clinical Practice. 2022;13(2):59-65
pages 59-65 views

Reviews

Cellular immunity in patients with COVID-19: molecular biology, pathophysiology, and clinical implications
Sсherbak S.G., Vologzhanin D.A., Golota A.S., Kamilova T.A., Makarenko S.V.
Abstract

The COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. From the viewpoint of factors critical to contain the virus, the neutralizing antibodies to SARS-CoV-2 garner most of the attention, however, it is essential to acknowledge that it is the level of the virus-specific T cell and B cell response that forms a basis for an effective neutralizing antibody response. T cell responses develop early and correlate with the protection, but they are relatively attenuated in the severe disease, in part due to lymphopenia. Understanding the role of different T cell subpopulations in the protection or the COVID-19 pathogenesis is critical to the prevention and treatment. The expression profile of different T cell subpopulations varies with the COVID-19 severity and is associated with the degree of T cell responses and the disease outcome. The structural changes in the genome, transcriptome, and proteome of SARS-CoV-2 promote the emergence of new variants of the virus and can reduce its interaction with antibodies and result in avoiding the neutralization. There is a strong correlation between the number of virus-specific CD4 T cells and neutralizing IgG antibody titers against SARS-CoV-2. During the primary viral infection, there is a wide variation in the cellular and humoral immune responses, patients with severe and prolonged symptoms showing highly imbalanced cellular and humoral immune responses. This review focuses on the generation and clinical significance of cellular immunity in the protection against severe acute infection and reinfection, as well as the potential involvement of seasonal coronavirus-specific cross-reactive T cells in response to SARS-CoV-2.

Journal of Clinical Practice. 2022;13(2):66-87
pages 66-87 views
Possibilities of using hyperbaric oxygen therapy at different stages of cardiac surgery
Krylov V.V., Kolchina E.Y.
Abstract

Nowadays, the evolution of cardiac surgery is impossible without a continuous improvement of all the treatment stages. One of the promising ways to achieve this goal is the active use of hyperbaric oxygen therapy in the preoperative preparation and postoperative rehabilitation. In this review, we present a short history of the hyperbaric oxygen therapy development in cardiac surgery, the pathophysiological and pathobiochemical mechanisms of its therapeutic effect and the scenarios for its use in the preoperative preparation and postoperative rehabilitation of cardiac surgery patients. The introduction of hyperbaric oxygen therapy into cardiac surgery can improve the results of the surgical treatment, as well as reduce the times of the preoperative preparation and postoperative rehabilitation of cardiac surgery patients, that will significantly increase the quality and efficiency of cardiac surgery.

Journal of Clinical Practice. 2022;13(2):88-97
pages 88-97 views
The main side effects of statins in clinical practice
Chaulin A.M.
Abstract

Statins have long occupied a central place in cardiovascular medicine, being an integral component of the prevention and treatment of atherosclerotic cardiovascular diseases (coronary heart disease and its main clinical forms, angina pectoris and myocardial infarction; transient ischemic attacks, ischemic strokes, etc.). By blocking a key enzyme of cholesterol biosynthesis, 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMG-CoA-reductase), statins normalize the parameters of the lipid spectrum, primarily, the serum levels of atherogenic low-density lipoprotein cholesterol. However, in addition to the beneficial effects of statins, side effects are also characteristic, which are a significant problem in modern clinical practice due to the fact that they can cause dangerous disorders, forcing physicians to reduce dosages or completely cancel these drugs. Understanding the side effects and the mechanisms underlying their formation is important for improving the measures for the early detection, prevention and treatment of those disorders. This article discusses such side effects of statins as myotoxicity, hepatotoxicity, nephrotoxicity. The pathogenetic mechanisms underlying these toxic effects of statins are discussed. A particular attention is paid to the effect of statins on the oxidative stress, the mechanisms of oxidative damage to cellular macromolecules (lipids, proteins and DNA) and their potential role in the development of myotoxicity, hepatotoxicity and nephrotoxicity.

Journal of Clinical Practice. 2022;13(2):98-107
pages 98-107 views

Case report

The problems of the operated spine. Treatment of transpedicular fixation failure and the adjacent level pathology: A clinical case
Ochkal S.V., Sorokovikov V.A., Seliverstov P.V., Larionov S.N., Potapov V.E., Zhivotenko A.P.
Abstract

Background: Among the modern methods of surgical treatment of the lumbar spine’s degenerative stenoses, decompressive-stabilizing surgical interventions using transpedicular screw-rod structures occupy an important place. The use of metal structures is justified not so much by the degenerative process specifics, degree or length of stenosis, but by the presence of instability in the spinal motion segments. In turn, the widespread use of fixing structures has naturally led to an increase in the specific complications, reaching 10–20 per cent of the total number of operated patients. One of the threatening complications of decompressive-stabilizing operations is the fracture of structural elements, often with the formation of pathology at the adjacent levels. The reasons for these complications are associated with both an erroneous choice of the construct parameters and a violation of the technique for installing the transpedicular fixation system (TPS). Clinical case description: The article presents an analysis of the clinical symptoms appearing with the formation of the adjacent level syndrome due to a fracture of the TPS system screws used to treat central stenosis of the spinal canal at the LIV -LV level. The correction of the pathology was carried out with a repeated surgical intervention. Conclusion: This clinical example draws attention to the combination of the adjacent level syndrome with a fracture of the metal structure in a patient after a decompressive-stabilizing operation using screw-rod fixation. An early diagnosis and adequate correction of the pathology helps to avoid the aggravation of symptoms and disability of patients.

Journal of Clinical Practice. 2022;13(2):108-113
pages 108-113 views
Reimplantation of a drainage valve device in refractory glaucoma. A clinical case
Starostina A.V., Khabazova M.R., Burlakov K.S., Arisov A.A.
Abstract

Background: Implantation of various drainage devices is one of the treatments for refractory glaucoma, resistant to traditional surgical methods. The most commonly used glaucoma drainage device for refractory glaucoma is the Ahmed glaucoma valve. However, the long-term success rate of the surgery may be limited because of the development of complications during the late postoperative period. The complications do not allow the control of the achieved intraocular pressure (IOP) level. In such cases, a repeated implantation of the Ahmed valve may be one of the options for the surgical treatment. Clinical case description: Second Ahmed valves were implanted to two patients with refractory repeatedly operated glaucoma at the Department of surgical glaucoma treatment of the S. Fyodorov Eye Microsurgery Federal State Institution in Moscow. Previously, both patients had the Ahmed valves installed at their places of residence. During the postoperative period, one patient was found to have an encapsulated cyst around the drainage body, and later the revision of the operation area was performed. As a result of the repeated Ahmed valve implantation, the IOP compensation was achieved 9 months after the surgery. Conclusion: A repeated implantation of the Ahmed valve may be an option for the surgical treatment, if the first implant failed to control the IOP, in order to compensate the IOP and preserve the visual functions in patients with refractory repeatedly operated glaucoma.

Journal of Clinical Practice. 2022;13(2):114-120
pages 114-120 views


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