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 1 (2022)

Original Research

Sex differences in the connectome of the human brain according to an MR-tractography study
Gubskiy I.L., Gumin I.S., Shorikov M.A., Beregov M.M., Gubsky L.V., Lelyuk V.G.

Background: The gender differences in the brain anatomy play an important role in planning and analysis in a lot of studies of the brain. Despite most animal studies being performed on the animals of only one sex, clinical studies generally enroll both males and females. Keeping this fact in mind, learning the gender differences in the white matter structure is important for those studies which deal with the white matter changes. These differences should be considered on the stages of planning and evaluation of the results.

Aims: Evaluation of the gender differences in the white matter pathways in healthy subjects.

Methods: 21 women and 20 men were enrolled in the study. All the subjects underwent MR-tractography, then the anatomic connectome was composed and the differences were evaluated using the tracts quantitative anisotropy (QA) evaluation.

Results: The gender differences were found in the white matter pathways with the prevalence of quantitative anisotropy in women, observed in a larger number of tracts than in those of men. QA was prevalent in a lot of fascicli that form major pathways in both groups: corpus callosum, dominant arcuate fasciclus, inferior fronto-occipital, inferior and superior right longitudinal pathways.

Conclusions: The white matter pathways in males and females are different not only within the major tracts but also for small fascicli that form tracts.

Journal of Clinical Practice. 2022;13(1):5-13
pages 5-13 views
Possibility of blood test parameters usage in the evaluation of COVID-19 patients’ inflammatory status
Nekrasova L.A., Jain M., Gubenko N.S., Budko A.A., Samokhodskaya L.M., Orlova I.A., Kamalov A.A.

Background: C-reactive protein (CRP) is a key laboratory biomarker for anti-inflammatory treatment initiation. Unfortunately, biochemical blood analyzers are not always easily accessible in medical institutions located far from major regional health facilities.

Aim: To develop an approach for inflammatory status estimation based on blood test results in patients with COVID-19 in cases with limited laboratory equipment availability.

Methods: The present retrospective study included 423 patients (male 54.6%; female 45.4%; mean age 59.1 years) receiving hospital treatment due to COVID-19 in Medical Research and Educational Center of Lomonosov Moscow State University from April 21st to June 13th 2020. All patients donated blood for full biochemistry and hematology testing and underwent chest computer tomography (CT).

Results: CRP levels (>60 mg/L) qualitative estimation model was developed based on hematologic test results. It included erythrocyte sedimentation rate and neutrophils to lymphocytes ratio. According to the results of Receiver Operating Characteristic (ROC) analysis present model was characterized by sensitivity of 70.2%, specificity of 74.6%, and area under the ROC-curve of 0.781. Comparison of key clinical parameters reflecting COVID-19 severity, such as length of hospitalization, lung damage at CT (hospital admission and discharge), revealed statistically significant difference between groups with routinely measured CRP levels ≤60 mg/L and >60 mg/L for all the above-mentioned parameters (p <0.05). These differences remained significant when measured CRP levels were substituted with estimated CRP values, indicating interchangeability of these approaches to CRP levels determination, regarding clinically important parameters.

Conclusions: Presented model for inflammatory status estimation based on hematologic test results might be used to overcome clinical challenges in cases with limited laboratory equipment availability.

Journal of Clinical Practice. 2022;13(1):14-21
pages 14-21 views
Toxic desomorphine encephalopathy due to the use of “Krokodil”: clinical and neuroimaging features
Nartov S.E., Parkhomenko E.V., Ekusheva E.V., Karpov D.Y.

Background: Toxic desomorphine encephalopathy (TDE) is a pathological condition that develops as a result of the intravenous use of a drug called “Krokodil” containing desomorphine, made in the artisanal conditions using codeine-containing drugs, organic solvents (gasoline), iodine and red phosphorus. This disease is more often observed in the CIS countries. In addition to the acute and chronic pathological conditions with the damage to various organs, the use of “Krokodil” is characterized by pronounced extrapyramidal manifestations in the form of dystonia, parkinsonism, postural disorders, as well as the occurrence of cognitive and affective disorders.

Aims: To find the clinical and neuroimaging features of toxic desomorphine encephalopathy, as well as possible methods of its treatment.

Methods: A clinical analysis of the medical documentation of 21 TDE patients (11 women and 10 men) with a history of the use of “Krokodil” was carried out, the patients had been under observation from 2014 to 2021. All the patients underwent a clinical physical and neurological examination, 14 of them underwent neuroimaging (brain MRI and/or MSCT). The observation of these patients revealed a number of characteristic clinical and neuroimaging features inherent in the majority of drug addicts.

Results: The clinical picture of patients with TDE was dominated by movement disorders. All the patients had pronounced postural disorders and gait disturbance. Parkinsonism was observed in 20 of 21 patients. The hyperkinetic syndrome was presented in 17 patients (80.9%) and was manifested by dystonia of various localization with polymorphic manifestations. The brain MRI data taken from the «Krokodil» users for 3 years were characterized by symmetrical focal changes in the basal ganglia, brainstem, cerebellum and internal capsule of the thalamus in the form of an increase in the intensity of the MR signal in the T1 mode and attenuation in the T2-weighted images mode (7 of 11 cases), with the subsequent regression of these characteristics based on the results of the subsequent MRI studies.

Conclusion: The study results have revealed the clinical manifestations characteristic of TDE — polymorphic extrapyramidal disorders, as well as neuroimaging changes reflecting these data.

Journal of Clinical Practice. 2022;13(1):30-41
pages 30-41 views
Specficics of the pro-antioxidant and antioxidant status in children with acute pneumonia, depending on the severity of the pathological process and the etiological factor
Petrenko T.S., Husakova N.V., Maloletnikova I.M., Denisova O.V., Devichenskiy V.M.

Background: In the recent years, an increasing number of researchers, in addition to the standard causes of a particular pathology’s development, have been paying attention to changes in the immune, pro-antioxidant, psychosomatic and other systemic factors. The processes occurring in the body with the participation of reactive oxygen species are general biological mechanisms of tissue damage and protection. Their role has been described and proven in a variety of nosologies. However, the number of studies evaluating the interaction of prooxidants with antioxidants in children with acute pneumonia is quite few.

Aims: Analysis of the pro-/antioxidant status in children with acute pneumonia, depending on the severity of the pathological process and the etiological factor.

Methods: The main group consisted of 50 patients with acute pneumonia, who were divided into 2 subgroups according to the severity of the disease course. The comparison group consisted of 30 conditionally healthy children. In addition to the list of examinations of children with acute pneumonia, according to the clinical practice guidelines, Imax, S, t values were assessed in the study groups by the method of luminol-dependent chemiluminescence (CL) of the blood plasma, depending on the severity of the pathological process and the etiological factor.

Results: After conducting a ROC analysis in children in the acute period of pneumonia, we established the threshold values of the pro-/antioxidant status parameters: at the Imax level ≤28.1%; S ≤26.2%; t ≤0.34 min. the examined children had a more severe course of pneumonia. When Mycoplasma pneumoniae, Chlamydophila pneumoniae were detected in the sputum, the level of the pro-/antioxidant status parameters was lower (Imax=28.0%, S=36.0%, t=0.37 min) than that in children who had Gram-negative bacteria or Gram-positive bacteria in the sputum (Imax=46.0%, S=45.0; t=0.42 min); p ≤0.05.

Conclusion: Violations of the pro-/antioxidant status were noted in all the children we examined. The most pronounced violations of the pro-/antioxidant status were detected in children with acute community-acquired severe pneumonia caused by atypical pathogens — M. pneumoniae, C. pneumoniae. In addition, the ROC analysis made it possible to determine the threshold values of the pro-/antioxidant status parameters for assessing the severity of pneumonia in children during the acute period of the disease.

Journal of Clinical Practice. 2022;13(1):22-29
pages 22-29 views


Rehabilitation during the COVID-19 pandemic
Golota A.S., Kamilova Т.A., Makarenko S.V., Sarana A.M., Sсherbak S.G.

The COVID-19 pandemic has affected the entire healthcare system, from emergency care, intensive care units, internal medicine wards, outpatient care to home care. The pandemic continues and brings a large number of patients with COVID-19-associated postintensive care syndrome suffering from physical, mental and cognitive impairments that threaten their return to normal life. The complexity and severity of illness in patients recovering from severe COVID-19 requires a coordinated and systematic approach to be applied as early as possible during the recovery phase. Considering the multiorgan dysfunction, debility, pulmonary, neurological, neuromuscular and cognitive complications, rehabilitation professionals can play an important role in the recovery process for individuals with COVID-19. Complications of COVID-19 can be reduced by (1) multidisciplinary rehabilitation, which begins early and continues throughout the hospital stay; (2) providing patient/family education for self-care after discharge from inpatient rehabilitation, and (3) continuing rehabilitation care in the outpatient setting, and at home either in person or with the help of telerehabilitation.

Journal of Clinical Practice. 2022;13(1):42-65
pages 42-65 views
Frailty and senile apathy in the everyday clinical practice in the conditions of COVID-19
Veselova D.К., Belopasov V.V.

The article covers the pathogenesis, clinical manifestations, and diagnostic criteria of frailty and senile apathy in the elderly. Special attention is paid to sarcopenia: the phenotypic classification and modern approaches to the treatment are discussed. The knowledge and understanding of the main pathogenetic links of sarcopenia, frailty and senile apathy, as well as the development of a single therapeutic line for these pathological conditions can significantly improve the life quality and expectancy of the elderly.

Journal of Clinical Practice. 2022;13(1):66-78
pages 66-78 views
Aging and “rejuvenation” of resident stem cells — a new way to active longevity?
Baklaushev V.P., Samoilova E.M., Kalsin V.A., Yusubalieva G.M.

This review presents the current data on the methodology for assessing the biological and epigenetic age, describes the concept of the epigenetic clock, and characterizes the main types of resident stem cells and the specifics of their aging. It has been shown that age-related changes in organs and tissues, as well as age-related diseases, are largely due to the aging of resident stem cells. The latter represent an attractive target for cell rejuvenation, as they can be isolated, cultured ex vivo, modified, and re-introduced into the resident niches. Two main methodologies for the cellular rejuvenation are presented: genetic reprogramming with «zeroing» the age of a cell using transient expression of transcription factors, and various approaches to epigenetic rejuvenation. The close relationship between aging, regeneration, and oncogenesis, and between these factors and the functioning of resident stem cell niches requires further precision studies, which, we are sure, can result in the creation of an effective anti-aging strategy and prolongation of human active life.

Journal of Clinical Practice. 2022;13(1):79-91
pages 79-91 views

Case report

Successful application of conditioned culture medium for the treatment of a chronic wound of an amputation stump: a clinical case
Cherepanin A.I., Pavlova O.V., Kalsin V.A., Konoplyannikov M.A., Kucherova O.N., Baldin V.L., Deryabin S.V.

Background: Amputation of the lower extremities is a necessary procedure to save a patient with critical arterial and neurotrophic disorders in the lower extremities. The amputation stump-related complications develop in many patients with diabetes mellitus (up to 40% of the total population).

Clinical case description: Patient Yu., 64 years old, was admitted on October 19, 21 for an outpatient treatment of purulent-necrotic wounds of the amputation stump of the right lower limb. А high amputation was performed on September 24, 2021 due to thrombosis of the femoral-tibial bypass, installed on September 08, 2021 (bypassing below the knee joint gap with a Vascutek 7 mm synthetic prosthesis on the right) and the development of critical ischemia of the right lower limb with necrosis of the distal phalanges of the right foot toes. The wound was assessed according to the Bates-Jensen scale (BJ) and examined according to the developed protocol. The wound treatment was carried out according to an individual plan using a conditioned culture medium from mesenchymal stem cells (CM-MSCs), which stimulates angiogenesis and improves remodeling and recovery in the wound area. CM-MSC application made it possible to reduce the healing time and achieve a scarless closure of the tissue defect.

Conclusion: The use of CM-MSC can be an effective method for healing a purulent-necrotic postoperative wound resulting from amputation of a limb in patients with critical ischemia of the lower extremities.

Journal of Clinical Practice. 2022;13(1):92-98
pages 92-98 views
Excessive hypercorrection after an open wedge high tibial osteotomy: a clinical case
Prizov A.P., Zagorodnii N.V., Nikitin A.A., Lazko F.L., Belyak E.A., Akhpashev A.A., Lazko M.F.

Background: Currently, there is a tendency to increasing the proportion of knee joint organ-preserving surgeries. High tibial osteotomy (HTO) has proven itself a good method for the treatment of the knee joint varus deformity in extra-articular deformity cases. The question of the perfect angle of correction, which will not significantly impair the biomechanics of the knee and adjacent joints, remains controversial, as well as the issue of preventing excessive hypercorrection as an osteotomy complication.

Clinical case description: A clinical case of a 59-year-old patient who underwent primary and revision HTOs is analyzed in this article. The patient had a varus deformity of the left lower limb with isolated medial knee osteoarthritis. The patient’s body mass index (BMI) was 28 kg/m2. The patient complained only of pain and a limited range of motion in the knee joint. According to the arthroscopy and magnetic resonance imaging (MRI) data, there was a cartilage damage classified as Outerbridge 4 stage of the medial compartment. There were no signs of a lateral compartment cartilage damage and patellofemoral joint arthritis. The varus deformity of the knee joint was 10°. The patient underwent a medial high tibial open wedge osteotomy. During the preoperative planning, topograms of the lower limb with weight bearing were used. The clinical status before the operation, according to the used scales, was as follows: Knee injury and Osteoarthritis Outcome Score (KOOS) — 46 points, Visual Analogue Scale (VAS) — 7 cm, American Orthopaedic Foot and Ankle Society (AOFAS) — 92 points. 6 months after the initial surgery, the clinical status was as follows: knee joint VAS — 1 cm, ankle joint VAS — 5 cm, KOOS — 88 points, AOFAS — 63 points. During the clinical examination and according to the instrumental studies, excessive valgus hypercorrection of 11.2° was noted. Also, the tibial plafond inclination (TPI) and the talar inclination (TI) were significantly increased. 1.5 years after the primary osteotomy, a revision closed wedge osteotomy was performed. The valgus deformity of the knee joint became 3°, the axis of the ankle joint changed to the normal values. The clinical and functional results 6 months after the revision osteotomy were the following: KOOS — 92 points, AOFAS — 99 points, pain in the knee and ankle joint — 1 cm by the VAS scale.

Conclusions: The case showed that the careful preoperative planning and the use of additional methods for monitoring the intraoperative correction were important. Excessive valgus hypercorrection promotes good regeneration of the medial compartment cartilage; however, it overloads a lateral compartment and adversely affects the ankle joint and foot.

Journal of Clinical Practice. 2022;13(1):99-106
pages 99-106 views
Case reports: spondylodiscitis and epiduritis after suffering COVID-19
Ustenko I.I., Kushnir Y.B., Amelin A.V., Gotovchikov A.А., Goranchuk D.V., Kulikov A.N.

Background: The study analyzes a possible rare complication of COVID-19 in the form of spondylodiscitis, including that followed by epiduritis, in patients who survived COVID-19 characterized by severe pneumonia, respiratory failure and systemic inflammatory response syndrome (SIRS).

Clinical case description: Three clinical cases of patients are presented, each of whom had high fever, SIRS with a significant increase in the laboratory markers of inflammation (C-reactive protein (CRP), leukocytosis, erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, ferritin), bacterial pneumonia, and severe hemostasis disorders. Despite an antibiotic therapy with broad-spectrum drugs, the development of spondylodiscitis was observed, manifested as acute pain syndrome in the lumbar spine. In the first patient, against the background of a massive antibacterial therapy, revisions of purulent foci, therapy with glucocorticosteroids (GCS), and a surgical treatment, there was significant positive dynamics in the form of the pain syndrome relief. The second patient showed positive dynamics against the background of a conservative antibacterial therapy. The third patient, with a paravertebral abscess at the level of developed spondylodiscitis, received a massive antibiotic therapy combined with GCS, and was operated for the spinal cord decompression.

Conclusion: Spondylodiscitis and epiduritis may be possible complications of COVID-19, including those resulting from the immunosuppressive therapy, which is actively used to stop the cytokine storm.

Journal of Clinical Practice. 2022;13(1):107-117
pages 107-117 views
Difficulties in diagnosing paroxysmal nocturnal hemoglobinuria in a municipal internal disease hospital
Zinnatullina A.R., Ishmurzin G.P.

Background: The purpose of this work is to present a case of paroxysmal nocturnal hemoglobinuria in the clinical practice of an internist for the purpose of differential diagnosis with other diseases with the jaundice syndrome in a city hospital.

Clinical case description: Patient H., 51-year-old, was seen at the emergency department of the city hospital due to the periodic appearance of jaundice with dark-colored urine and fever. The physical and laboratory examination methods revealed an enlargement of the spleen, signs of mild hemolytic anemia, severe thrombocytopenia, a significant increase in the markers of cytolysis and cholestasis. Proteinuria and cylindruria were noted in the urine analysis. In terms of a differential diagnosis, Gilbert’s syndrome, viral hepatitis, hemorrhagic fever were considered.

Conclusion: Based on the data obtained, hemolytic and uremic syndromes were suspected. A therapy with iron preparations, vitamin B12, infusions of glucose and saline was applied with the positive clinical and laboratory dynamics. GPI-linked glycoproteins were determined on the surface of red blood cells (CD59), neutrophils (CD 24/FLAER), and monocytes by FLAER-/CD14 flow cytometry, which confirmed the diagnosis of paroxysmal nocturnal hemoglobinuria.

Journal of Clinical Practice. 2022;13(1):118-122
pages 118-122 views
Idiopathic longitudinally extensive myelitis: a brief historical excursion (review) and own clinical observation
Turuspekova S.T., Almakhanova K.K., Nurguzhaev E.S., Nurzhanova R.B., Demesinova B.K., Mukasheva T.Z., Stepuk N.V.

Background: Idiopathic longitudinally extensive transverse myelitis is defined as a focal spinal cord lesion that involves three or more segments of the spinal cord as shown by neuroimaging, and results in a profound disability. The clinical picture of a patient with idiopathic longitudinally advanced transverse myelitis is often dramatic and may consist of paraparesis or tetraparesis, sensory disturbances, and pelvic dysfunction. Idiopathic longitudinally advanced transverse myelitis is a common manifestation of the neuromyelitis optica spectrum disorders, but can also occur in various other autoimmune and inflammatory diseases of the CNS, such as multiple sclerosis, sarcoidosis, or Sjogren’s syndrome, or in infectious diseases involving the CNS. It is less likely to occur in isolation, as the only manifestation of a demyelinating disease of the nervous system of an unknown etiology (idiopathic myelitis).

Clinical case description: The clinical observation presented in the article demonstrates the difficulties of establishing a nosological diagnosis in the case of a monophasic course of TM in the absence of other autoimmune and infectious diseases of the central nervous system. The patient with idiopathic longitudinally distributed TM had no visual disturbances and no antibodies to aquaporin 4 and to myelin oligodendrocyte glycoprotein (MOG-IgG) with twice repeated tests.

Conclusion: In this regard, it is important to dynamically monitor the clinical manifestations and MRI signs in patients with an isolated lesion of a demyelinating nature in the form of longitudinally extensive transverse myelitis.

Journal of Clinical Practice. 2022;13(1):123-128
pages 123-128 views

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