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 3 (2020)

Original Research
Specifics of the hemodynamics in hemodialysis patients with hand ischemia
Zakhmatova T.V., Koen V.S., Holin A.V.
Abstract

Background. Successful hemodialysis is impossible without an effective vascular access. However, the average duration of its normal functioning is 2.5–3.0 years that is associated with complications, one of them being steal syndrome of the hand.

Aim: to examine the hemodynamic parameters in the permanent vascular access and forearm arteries in chronic hemodialysis patients with ischemic steal syndrome of the hand. Methods. Duplex ultrasound was performed in 550 patients, 517 of which (94.0%) had an arteriovenous fistula, 33 (6.0%) had an arteriovenous graft. The inflow artery, anastomotic zone, outflow vein and arteries distal to the anastomotic zone were assessed during ultrasound examination; linear and volumetric speed indicators, peripheral resistance indices were measured.

Results. Steal syndrome was detected in 2.7% of cases. The main causes are the inflow artery alterations due to diabetes and atherosclerosis that lead to insufficient growth of the blood flow through the artery (20.0%); substantial anastomosis diameter that causes a vein dilation and significant increase in the access flow (13.3%); insufficient blood flow through the ulnar, anterior interosseous arteries and the absence of collateral branches not compensating for the retrograde blood flow in the radial artery distal to anastomosis (40.0%); microcirculatory dysfunction of the hand and alterations of the regulation mechanisms of the resistive vessels tone (26.7%).

Conclusion. Dynamic ultrasound examination of the vascular access can detect adverse changes in the hemodynamics and avoid severe ischemic complications. The main contribution to the steal syndrome development belongs to the condition of the forearm arteries not participating in the fistula formation and the hand microvasculature.

Journal of Clinical Practice. 2020;11(3):5-12
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Options for using cellular cardiomyoplasty for coronary heart disease
Mykhaylichenko V.Y., Kostyamin Y.D., Samarin S.A.
Abstract

Background. Despite a significant arsenal of medications and methods of surgical correction of myocardial blood supply, treatment of some forms of coronary heart disease remains relevant. Aim of the work is to analyze the effectiveness of the use of mesenchymal stem cells (МSC) of bone marrow in autologous transendocardial transplantation in some forms of IHD.

Methods. In the near and long-term results, we analyzed the histories and diseases and conducted a survey of 68 patients. Of the 68 patients, the largest group was men — 53 (77.9%), women were much fewer — 15 (22.1%). Then we formed 4 groups (17 patients each): 1 group — control — patients received standard drug therapy; Group 2 — to patients who received standard therapy, empty myocardial injections were performed using a catheter and the NOGA XP navigation system; Group 3 — auto-CCK was administered intravenously to patients; 4 group — against the background of therapy, transendocardial auto-МSС was administered.

Results. When analyzing the patient’s subjective sensations in group I, after 3 months in group 1, 4 patients (32%) noted improvement, unchanged — 11 (64.7%), worsening — 2 (11.8%) and significant worsening 1 (5.9%). In group 2, improvement was in 1 patient, which was 5.9%, unchanged — 13 (76.5%), worsening — 2 (11.8%) and significant deterioration — 2 (11.8%). In group 3, improvement was observed in 5 patients — 29.4%, significant improvement in 1 (5.9%), deterioration and significant deterioration in 1 patient (5.9% each, respectively). In group 4 unchanged — 6 (35.3%) patients, improvement — 7 (41.2%), significant improvement — 4 (32%), worsening — 1 (5.9%). Cell transplantation, regardless of the method of administration, increases the EF and reduces the EDV of the left ventricle, more significantly in the group with a transendocardial route of administration.

Conclusion. In accordance with published data, we obtained similar data — transplantation of human bone marrow SSC with autologous administration causes a positive effect in the form of increased EF LV, decreased EDV of the LV, increased exercise tolerance and a significant improvement in patients’ well-being. It should be noted that intravenous and intracoronary administration of auto-МSC is less effective in the studied parameters than transendocardial introduction of cells into the myocardium.

Journal of Clinical Practice. 2020;11(3):13-22
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Comparative analysis of the oct and microperimetry data to assess the state of the central regions of the retina following the relapse of a macular rupture
Shishkin M.M., Larina E.A., Fayzrakhmanov R.R., Pavlovsky O.A., Sukhanova A.V., Karpov G.O.
Abstract

Background. In 8–10% of cases after the surgical treatment, macular ruptures do not close. Aim: to assess the morphological and functional parameters of the macular area following the surgical closing of previously operated macular ruptures using a free flap of the internal limiting membrane and silicone oil tamponade.

Methods. This study involved 31 patients, all the patients underwent a surgical treatment applying a free ILM flap and silicone tamponade, the standard diagnostic procedures and optical coherence tomography and microperimetry were also used (before the operation, on the 14th and on the 30th day after the operation).

Results. The change in the morphological parameters of the retina directly correlates with the change of the functional parameters of the macular zone, and a peak of the increase in the retina photosensitivity occurs in the early postoperative period with a slight further increase in the long-term postoperative period.

Conclusions. The surgical treatment of unclosed macular holes, namely the creation of a “free flap” of the internal limiting membrane, or a “plug”, as well as the use of silicone tamponade, ensures a reliable positiveanatomical and functional postoperative result.

Journal of Clinical Practice. 2020;11(3):23-28
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Varicose disease and harmful production factors
Barabash V.I., Tskhai V.F., Semichev E.V., Mayer V.V.
Abstract

Background. Varicose disease is the most wide-spread vascular disease of the lower extremities. The form of occupation and work conditions significantly affect the cardiovascular system due to regular and unavoidable action of the human body.

Aim: to determine the influence of hazardous work conditions on the incidence of varicose veins of the lower extremities among the persons subjected to periodic medical examinations; to identify the most important factors in the development of this pathology; to propose methods for preventing the occurrence of varicose veins in the manufacturing sector with hazardous conditions. Methods. Analysis of the outpatient histories (account form No. 025 \ у-04) of employees having periodic medical examinations was performed, with 528 female and 1489 male patients in total. The analysis of the outpatient histories, as well as processing of the obtained material were accomplished using the universal statistical package of Statgraphics Plus for Windows.

Results. It has been established that hazardous work conditions, such as vibration, increase the incidence of varicose veins of the lower extremities, and the “hazardous” work experience plays the main role in increasing the incidence of this pathology.

Conclusion. Hazardous work factors affect the incidence of the varicose disease of the lower extremities towards its elevation. The age, “hazardous” work experience and conditions associated with vibration play the major role in the increase of the disease incidence. A set of measures aimed at the prevention of varicose disease in the manufacturing sector has been suggested as a result of the study.

Journal of Clinical Practice. 2020;11(3):29-34
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Surgical treatment of the knee joint contractures after total knee arthoplasty
Akhpashev A.A., Brizhan L.K., Artemiev A.A., Bolotnikov M.A., Shipulin A.A., Kashoob A.M.
Abstract

Background. The development of contractures after total knee replacement is most often associated with arthrofibrosis and constitutes up to 1.3–5.7% of the total number of cases of joint replacement. The conservative treatment is ineffective. Arthrolysis is pathogenetically substantiated (arthroscopic or open).

Aim: assessment of the effectiveness of arthrolysis as a method of treating knee joint contractures after arthroplasty, comparison of the results of arthroscopic and open arthrolysis, analysis of complications.

Methods. We compared two groups in a retrospective study. In group 1, 57 patients underwent arthroscopic arthrolysis. In group 2, 54 patients underwent open arthrolysis. The operations were performed from 2015 to 2019, the observation period ranged from one year to three years. As criteria for the result of the treatment, the KSS data were used (general and functional assessment of the knee joint), as well as, separately, the amplitude of movements in the joint before surgery and at different times after it.

Results. One of the results of this work was the optimization of arthroscopic arthrolysis technique. The surgical access and the joint revision sequence were improved. According to the KSS scale and range of motion, the best results were obtained in group 1. Especially important is the lesser number of complications in comparison with the 2nd group requiring repeated interventions, including revision arthroplasty. In the 1st group, we observed 3 such cases (5.3%) , in the 2nd group — 7 (13.0%).

Conclusions. Arthroscopic arthrolysis is a less traumatic and more effective treatment for arthritis of the knee. It seems appropriate to gradually replace open arthrolysis by the arthroscopic approach.

Journal of Clinical Practice. 2020;11(3):35-42
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Symmetry and gender differences of the knee joint adduction moment
Malkov A.B., Kondrat’ev S.N., Abros'kina M.V.
Abstract

Background. Gonarthrosis is one of the most insidious degenerative diseases, which has a number of gait biomechanical predictors. Of these, the most studied is the knee joint adduction moment in the support phase, however, there is a lack of research devoted to its reference values among various age and gender groups.

Aim. Evaluation of the gender and functional body asymmetry effect on the peak moments of knee joint adduction in healthy volunteers. Methods. The study was conducted on 38 healthy volunteers (17 men and 21 women) aged 20–45 years using a «Vicon Motion Capture Systems» motion capture hardware-software complex by Vicon (United Kingdom). A comparative assessment was made for the first and second peaks’ amplitude of the knee joint adduction moment in the support phase. The symmetry was evaluated for both peaks in general, as well as separately for men and women. The gender differences for both peaks were evaluated in total for the right and left lower limbs.

Results. The absence of significant intergroup differences in the amplitude of both peaks of the knee joint adduction moment between the right and left legs, irrespectively of gender (p>0.05), was revealed, which demonstrates the symmetry of the adduction forces acting on the knee joint in the support phase. When comparing the amplitudes of both peaks of the knee joint adduction moment in men and women, significant differences were absent for the first peak (p>0.05), but a significantly higher second peak was observed in males (p<0.05).

Conclusion. The obtained variability aspects of the peak moments of knee joint adduction will find their application in the functional diagnostics using the motion capture technology.

Journal of Clinical Practice. 2020;11(3):43-49
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Reviews
Stenosis of the vertebral canal of the lumbar spine
Yarikov A.V., Smirnov I.I., Perlmutter O.A., Fraerman A.P., Kalinkin A.A., Sosnin A.G., Khomchenkov M.V.
Abstract

The overall incidence of symptomatic lumbar spinal stenosis is about 10–15% among persons aged 50–70 years. Due to the aging of the population, the incidence of this pathology is constantly growing. The desire of older patients to preserve their quality of life and their functional abilities, along with the improvement of surgical techniques, leads to an increase in the number of surgical interventions for lumbar stenosis. This publication describes the classification of spinal canal stenosis. The clinical picture of this disease has been studied in detail. A special attention is paid to such diagnostic methods as computed tomography (CT), radiography, CT-myelography, magnetic resonance imaging (MRI). Various methods of surgical treatment — decompression and decompression-stabilization — are described in detail.. The efficiency of various types of decompression operations are 72–80%, the results of surgery not differing statistically between the types of decompression (hemilaminectomy, interlaminectomy). Decompression-stabilization operations are used for progressive degenerative spinal deformity, destabilization after the surgical treatment, and disruption of the vertebral-pelvic relations. Currently, the following types of stabilization are used in the lumbar stenosis surgery: ALIF, PLIF, PLF, TLIF, XLIF, OLIF, and transpedicular fixation. The rate of complications in the stabilizing interventions is 27.6%; after decompression operations — 9.7%. The frequency of revision operations is also higher after stabilization — 10.3%, while after decompression it is 6.5%, which makes us cautious about these types of interventions. Systems of interosseous fixation are also used in the treatment of lumbar stenosis. In the 14 years of followup after interosseous fixation and decompression in 142 patients, 30 (21.1%) patients underwent revision interventions, with chronic pain (38.5%) and disc herniation (42.3%) being the main indication for repeated surgery in 26 of them.

Journal of Clinical Practice. 2020;11(3):50-60
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The role of OCT angiography in a study of retinal perfusion after endovitreal intervention due to rhegmatogenous retinal detachment
Fayzrakhmanov R.R., Sukhanova A.V., Pavlovsky O.A., Larina E.A.
Abstract

OCT angiography is a non-invasive method of the qualitative and quantitative analysis of the retinal perfusion. After rhegmatogenous retinal detachment and vitrectomy with endotamponade, the retinal perfusion changes. Aim: To analyze the data from the clinical studies that evaluate the changes in the blood microcirculation of the retina and choroid and theireffect on the visual acuity by OCTA after vitrectomy with endotamponade due to rhegmatogenous retinal detachment. A literature search was conducted using PubMed, Cochrane Library, and Embase until April, 2020. The authors conclude that the specific changes in the retinal perfusion after vitrectomy due to regmatogenous retinal detachment using various types of tamponade may act as predictors of visual outcomes, and also may become a basis for determining the optimal time of the silicone oil tamponade resolution. Evaluation of these changes according to the data obtained using OCTA is promising and little-studied. Thus, additional clinical studies are required.

Journal of Clinical Practice. 2020;11(3):61-67
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Beta-adrenergic and M-cholinergic receptor interactions in the pathogenesis of bronchial obstructive pulmonary diseases
Eremenko A.V., Zykov K.A.
Abstract

The crosstalk between the beta-2-adrenoceptor and M- cholinoreceptor systems in the airways plays one of the main roles in the pathogenesis of bronchoobstructive diseases. The interaction of M3-cholinergic receptors and beta2-receptors in the lungs can be characterized as functional antagonism. M3 activation can lead to desensitization of beta2 receptors. Beta2 receptors also limit the action of M3 receptors in various ways. In this case, M2 cholinergic receptors act as autoreceptors. On the one hand, they limit bronchoconstriction caused by a change in the conformation of the M3 cholinergic receptor, and, on the other hand, they are able to suppress the excessive bronchorelaxing effect that occurs when a beta2 receptor is activated. The knowledge of the crosstalk mechanisms can help in understanding the pathogenesis of bronchial obstructive diseases, in optimizing the existing treatment regimens for chronic obstructive pulmonary disease (COPD) and bronchial asthma (BA) and will create a new potential in the development of new drug groups

Journal of Clinical Practice. 2020;11(3):68-74
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Biomarkers of acute myocardial infarction: diagnostic and prognostic value. Part 1
Chaulin A.M., Duplyakov D.V.
Abstract

The morbidity and mortality rates for acute myocardial infarction (AMI) have been growing rapidly in the recent years, causing a significant socio-economic damage. The cardiospecific biomarkers play an important role in the diagnosis and prediction of AMI. The purpose of this review is to summarize the information about the main existing cardiac biomarkers and their diagnostic and prognostic value for patients with AMI. The currently existing cardiac biomarkers of AMI may be divided into several groups: biomarkers of necrosis and ischemia of cardiomyocytes, neuroendocrine biomarkers, inflammatory biomarkers, as well as a number of new AMI biomarkers, the diagnostic value of which is still poorly understood in AMI. In the first part of the review, we discuss the diagnostic and prognostic value of the biomarkers of myocardial necrosis and ischemia (aspartate aminotransferase; creatine phosphokinase and its isoform MB; cardiac troponins; myoglobin; BB-isoform of glycogen phosphorylase; ischemia-modified albumin; cardiac protein binding fatty acids) and neuroendocrine biomarkers of AMI (natriuretic peptides; adrenomedulline; copeptin, catestatin; components of the renin-angiotensin-aldosterone system).

Journal of Clinical Practice. 2020;11(3):75-84
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Case report
Single-stage removal of a neurinoma of the trigeminal nerve, localized in the posterior, middle cranial and infratemporal fossae. Clinical observation and review of literature
Vinokurov A.G., Kalinkin A.A., Bocharov A.А., Kalinkina O.N., Chupalenkov S.M.
Abstract

Background. In the course of the analysis of available foreign and domestic literature, 65 observations of trigeminal tumors with extracranial growth were found, the total removal of which was performed only in 20% of patients.

The aim of the study is to show the potential of skull base tumor surgery using an example of a successful surgical treatment of a patient with a spread trigeminal neurinoma located in the posterior, middle and infratemporal fossae, as well as to analyze the international scientific experience on this issue.

Clinical case description. A 60-year-old patient with a spread trigeminal neurinoma on the left was admitted to the Federal Scientific-Clinical Center of FMBA of Russia in February 2020. After an additional examination and preoperative preparation, a planned operation was performed — osteoplastic orbitozygomatic craniotomy, a microsurgical removal of the tumor through the subtemporal transcavernous approach. A good postoperative clinical result was obtained. An analysis of the available scientific literature on this problem has been performed. In the postoperative period, pain and neurological symptoms, hemifacial spasm completely regressed. 1.5 months after the operation, the tumor was shown to be totally removed by the control images.

Conclusion. Despite the extreme complexity of the pathology, the operation via the orbitozygomatic subtemporal transcavernous approach allows one to completely remove common and giant trigeminal neurinomas with a good functional result.

Journal of Clinical Practice. 2020;11(3):85-94
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A case of aggressive angiomyxoma. Differential diagnosis of abandoned nonorgan organ tumors (literature review with their own clinical observations)
Egorova E.A., Shaposhnikova E.A., Lezhnev D.A., Kleymenova E.P., Bazhin A.V., Semenova M.V., Truten V.P.
Abstract

Background. Aggressive angiomyxoma is a rare pelvic-perineal tumor that affects mainly women aged 30–50 years. It can simulate a bartholine cyst, abscess, lipoma, simple labial cyst or other soft tissue tumors of the pelvis. The main features of angiomyxoma are asymptomatic course and absence of metastasis with a tendency to deep invasion and relapses after a surgical treatment.

Clinical Case Description. The article describes a clinical case of aggressive angiomyxoma in a 33-year-old patient who was admitted to the emergency hospital with a suspected right sciatic hernia. According to the results of clinical and radiological examination, the formation of a presacral space was detected spreading to the m. levator ani on the right and into the tissue of the right ischiorectal fossa, infiltrating them. The specific features could not be identified at the initial stage of the diagnosis using the formal signs distinctive for the specific type of neoplasms. The diagnosis was made as a result of the morphological analysis of the surgical resection material of the tumor. The relapse was not detected in the following 6 months. Assuming the high risk of angiomixoma progression, the dynamic monitoring was continued.

Conclusion. This study and the literature data have demonstrated the typical difficulties of the differential diagnosis and prognosis of the disease, the need for a comprehensive approach using multiparametric magnetic resonance imaging, both at the initial stages of examination and when monitoring the effectiveness of treatment.

Journal of Clinical Practice. 2020;11(3):95-101
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Difficulties in treatment of acute coronary syndrome in a patient with end-stage chronic renal failure on program hemodialysis (case description)
Bocharov A.V., Sidorov D.V., Popov L.V.
Abstract

Background. The surgical treatment of the coronary heart disease (acute coronary syndrome) in patients undergoing program hemodialysis has its own characteristics, which are not fully reflected in the cardiological recommendations. In particular, coronary artery bypass grafting is preferable to stenting, the drug of choice among p2y12 platelet receptor blockers is clopidogrel, with the infeasibility of rosuvastatin prescription. All these points are often ignored by treating doctors from the cardiology team when choosing the optimal treatment strategy for patients in this group.

Description of the clinical case. The article presents a case of treating acute coronary syndrome in a patient undergoing program hemodialysis. The problems of coronary revascularization and the drug therapy in this category of patients are discussed, and the ways to solve them are shown by the example of this clinical case.

Conclusion. In special cases, such as acute coronary syndrome in patients with chronic renal failure who are on program hemodialysis, the endovascular treatment strategy should be considered only if the specifics of the prescribed pharmacotherapy are taken into account.

Journal of Clinical Practice. 2020;11(3):102-106
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Dural arteriovenous fistula — the rare cause of a pulsating noise in the ear
Belopasova A.V., Kadykov A.S., Belopasov V.V., Chechetkin A.O., Konovalov R.N., Krupnova K.V.
Abstract

The article describes the clinical manifestations of dural arteriovenous fistula, which is an abnormal communication between the arteries of the dura mater and venous sinuses or cortical veins. The information on the etiology and pathogenesis of such a malformation in the domestic literature is limited to a few publications. The diagnosis is based on the identification of visual (pulsation of the earlobe) and acoustic phenomena in the patient, as well as the presence of a shunt between the posterior auricular artery (a branch of the external carotid artery) and the dural venous sinuses revealed by neuroimaging, in particular MR angiography. The best treatment method is a neurosurgical intervention using endovascular surgery.

Journal of Clinical Practice. 2020;11(3):107-113
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Artery of percheron infarction of the brain: clinical case
Barilyak N.L., Ponomarev G.V., Shatsman I.G., Zhukovskaya N.V., Skoromets A.
Abstract

Background. The artery of Percheron is an anatomical version of the cerebral vasculature, in which one artery, departing from the proximal part of one of the posterior cerebral arteries, supplies the paramedial thalamus and the rostral part of the midbrain. The artery of Percheron stroke is often manifested by impaired consciousness, oculomotor disorders and neuropsychological symptoms. The diagnostics of the artery of Percheron stroke is carried out using computed tomography and/or magnetic resonance imaging (MRI). Intravenous thrombolysis and endovascular treatment methods are used upon admission within the “therapeutic window”. Further secondary prevention is recommended. The prognosis is favorable with the timely treatment. Clinical case description. A clinical case of a 43-year-old woman with acute oculomotor disorders is presented. The neurological examination revealed paresis of the vertical gaze, diplopia. MRI showed a bilateral acute infarction of both paramedial thalamuses. After the treatment, the patient was discharged with a minimal neurological deficit. Conclusion. Percheron artery occlusion is a rare form of cerebral infarction. Early diagnosis, in particular neuroimaging and angiography, allows for a timely adequate treatment, which has a positive effect on the rehabilitation.

Journal of Clinical Practice. 2020;11(3):114-119
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