Vol 12, No 1 (2021)

Original Research

Major predictive risk factors for а cytokine storm in COVID-19 patients (a retrospective clinical trials)

Anisenkova A.Y., Apalko S.V., Asaulenko Z.P., Bogdanov A.N., Vologzhanin D.A., Garbuzov E.Y., Glotov O.S., Kamilova T.A., Klitsenko O.A., Minina E.M., Mosenko S.V., Khobotnikov D.N., Sсherbak S.G.


Background: According to WHO, as of March 31, 2021, 127 877 462 confirmed cases of the new COVID-19 coronavirus infection were registered in the world, including 2 796 561 deaths (WHO Coronavirus Disease). COVID-19 is characterized by a wide range of clinical manifestations, from asymptomatic to a rapid progression to severe and extremely severe. Predictive biomarkers for the early detection of high-risk individuals have become a matter of great medical urgency. Aims: Search for the predictors of a cytokine storm in patients with COVID-19 infection and creation of a risk scale of this complication for practical applications. Methods: The study included 458 patients with confirmed COVID-19 infection with signs of viral lung lesions according to the computer tomography data. The patients were divided into 2 groups: those with a stable course of moderate severity (100 patients) and those with progressive moderate, severe and extremely severe course (358 patients). Results: It has been established that the main risk factors for the development of a cytokine storm in COVID-19 patients are the following: interleukin-6 concentration >23 pg/ ml, dynamics of the index on the NEWS scale ≥0, ferritin concentration >485 ng/ml, D-dimer concentration >2.1, C-reactive protein concentration >50 mg/l, number of lymphocytes in the blood <0.72×109/l, age ≥40 years. The cytokine storm incidence correlates with an increase in the number of risk factors. For the practical testing the scale was applied in 3 groups. In patients of the first group (0–1 factor) almost no cytokine storm risk was found, in the second group (2 -3 factors) the probability of the storm was 55% (increase by 35.5 times), in the third group (≥4 risk factors) it reached 96% (increase by 718 times). Conclusion: The diagnostic and monitoring criteria of a cytokine storm have been established in patients with COVID-19 infection. The developed prognostic scale allows identification of patients at high risk of developing a cytokine storm so that early anti-inflammatory therapy could be started.

Journal of Clinical Practice. 2021;12(1):5-15
pages 5-15 views

Long-term functional symptoms after total knee arthroplasty

Altukhova A.V., Kaurkin S.N., Skvortsov D.V., Akhpashev A.A., Mensakh L.


Background: The standard of the surgical treatment for arthrosis of the knee joint (KJ) at the later stages is total arthroplasty, which allows relieving the pain and eliminating the existing deformity. However, there are not enough data on the long-term results after the surgery that is important for understanding the dynamics of the recovery and predicting the result. Aims: Study of clinical, functional, and biomechanical symptoms in patients after total arthroplasty of the knee joint in the long-term period. Methods: 22 patients after knee joint replacement and 20 relatively healthy adults (control group) were examined in long-term periods. The biomechanics of walking was studied at an arbitrary pace. The temporal characteristics of the gait cycle, shock loads and movements in the hip joints (HJ) and KJ were recorded. We recorded the time characteristics of the walking cycle, shock loads and movements in the hip joint (HJ) and KJ. The patients were divided into two subgroups according to the results of the biomechanical study. The patients from subgroup 1 had good functionality with a swing amplitude of the knee joint of 50 degrees or more, the movement algorithm was preserved. The patients from subgroup 2 had a swing amplitude of up to 50 degrees, the movement algorithm was impaired. Results: The temporal characteristics of the waking cycle of knee arthroplasty patients did not differ significantly from the control group in the long term. Abduction-adduction and rotation movements in HJ and KJ show a decrease in the amplitudes, more pronounced in the second subgroup. The main changes in the kinematics of the hip joint are characterized by a decrease in the range of motion and a longer extension time during the support period, which was found for both sides, especially in the second subgroup. The greatest changes were observed in the kinematics of the knee joints movements. They included a decrease in the amplitude of all the movements, not only on the endoprosthesis side, but also on the opposite side. Conclusions: There is no complete restoration of the knee joint function after total arthroplasty in the long term. The function of both lower limbs is symmetrically decreased. The fact of functionally different (less severe and more severe) results may be associated with the initial functional state of the joint before arthroplasty or with the subsequent period of rehabilitation.

Journal of Clinical Practice. 2021;12(1):16-24
pages 16-24 views

Prevalence of hypovitaminosis D in COVID-19 patients in the intensive care unit

Bychinin M.V., Mandel’ I.A., Klypa T.V., Kolyshkina N.A., Andreichenko S.A.


Background: The prevalence of hypovitaminosis D has not been studied in the Russian Federation for the group of patients with severe and extremely severe COVID-19 in the intensive care unit (ICU). Aims: To study the prevalence of hypovitaminosis D in patients with COVID-19 treated in the ICU and to determine the relationship between the vitamin D status and disease outcome. Methods: The retrospective study included 103 adult patients with severe and extremely severe COVID-19 hospitalized in the ICU. Results: 94% patients (n = 97) showed a significant decrease in the concentration of 25 (OH) D in their blood serum — 11 ng/ml [7; 15 ng/ml]. 37% (n = 38) of patients showed vitamin D deficiency, 46% (n = 47) had severe vitamin D deficiency, 12% (n = 12) had vitamin D insufficiency, 5% (n = 6) had normal vitamin D levels. In the group of patients with vitamin D levels less than 10 ng/ml, the mortality rate was significantly higher than that in the group of patients with the levels of vitamin D exceeding 10 ng/ml (66% and 42%, p = 0.018). These two groups of patients also significantly differed in their age (p = 0.018), history of diabetes mellitus (p = 0.059), white blood cell count (p = 0.045), neutrophil to lymphocyte ratio (p = 0.017), D-dimer level (p = 0.05) and troponin T level (p = 0.054). Conclusion: A high incidence of vitamin D insufficiency in patients with COVID-19 treated in the ICU has been identified. Severe vitamin D deficiency was more often found in elderly patients with diabetes mellitus, and was associated with the increased mortality. The identified relationship of the vitamin D deficiency with the neutrophilic-lymphocytic index suggests an immuno-mediated effect on the outcome of patients with COVID-19.

Journal of Clinical Practice. 2021;12(1):25-32
pages 25-32 views


The immune response to the novel coronavirus infection

Fedorov V.S., Ivanova O.N., Karpenko I.L., Ivanov A.V.


This review summarizes the current knowledge on the humoral and T-cell immunity to the novel coronavirus infection. A special attention is paid to the viral proteins that induce production of antibodies, different types of immunoglobulins and their role in the protection against the virus as well as to the duration of the humoral immune response. In addition, a concise analysis of the T-cell immunity status during COVID-19 and its input into the antiviral defense is presented. The collected data demonstrating preservation of both the humoral and T-cell immunity are urgently needed in the medical professionals' community for evidence-based decisions on the immunity monitoring, estimation of (re)vaccination time, as well as for knowing the factors that should be considered while choosing the most effective vaccine. Finally, several directions for the future research are pointed out

Journal of Clinical Practice. 2021;12(1):33-40
pages 33-40 views

Genetics of COVID-19

Vologzhanin D.A., Golota A.S., Kamilova T.A., Shneider O.V., Sherbak S.G.


COVID-19 is characterized by a wide range of clinical manifestations, from asymptomatic to extremely severe. At the onset of the pandemic, it became clear that old age and chronic illness were the major risk factors. However, they do not fully explain the variety of symptoms and complications of the SARS-COV-2 coronavirus infection. The research on genetic risk factors for COVID-19 is still at its early stages. A number of mutations and polymorphisms have been identified that affect the structure and stability of proteins — factors of susceptibility to SARS-COV-2 infection, as well as a predisposition to the development of respiratory failure and the need for intensive care. Most of the identified genetic factors are related to the function of the immune system. On the other hand, the genetic polymorphism of the virus itself affects the COVID-19 spread and severity of its course . The genome of the virus accumulates mutations and evolves towards increasing contagiousness, replicative ability and evasion from the host's immune system. Genetic determinants of the COVID-19 infection are potential therapeutic targets. Studying them will provide information for the development of drugs and vaccines to combat the pandemic.

Journal of Clinical Practice. 2021;12(1):41-52
pages 41-52 views

MSC therapy for inflammatory bowel disease

Konoplyannikov M.A., Knyazev O.V., Baklaushev V.P.


Inflammatory bowel disease (IBD) belongs to the group of diseases characterized by idiopathic inflammation of the digestive tract organs. Two basic IBD types are distinguished: ulcerative colitis and Crohn’s disease. The IBD symptoms including vomiting and diarrhea, abdominal pain, rectal bleeding, anemia have a significant negative impact on the general patient’s state of health. Besides, IBD patients are susceptible to the risk of a number of serious diseases such as colorectal cancer, thrombosis and primary sclerosing cholangitis. More than 4 million people in the USA and Europe suffer from IBD, with 70000 new cases diagnosed yearly in the USA only.

In some cases, a surgical removal of the damaged digestive tract fragments is required to treat severe IBD forms. However, drug therapy of IBD has mainly been used in the last decades. The rate of remission with application of traditional IBD therapy is estimated as 20-30%, and is still no higher than 50% with the combined therapy. Cell therapy has been proven to be a very promising approach in the IBD treatment. In our review, we discuss mesenchymal stromal cells (MSC) and the most important preclinical and clinical results of their application for the IBD therapy.

Journal of Clinical Practice. 2021;12(1):53-65
pages 53-65 views

KRAS and NRAS genes mutations as biomarkers in the therapy of colorectal cancer and the basic methods of their detection

Brovkina O.I., Nikitin A.G.


Determination of the mutations' status in the KRAS and NRAS genes is a necessary requirement in the treatment of patients with colorectal cancer (CRC). Patients with certain mutations in the KRAS and NRAS genes are resistant to anti-EGFR drug therapy and have a lower median survival rate than those with WT (wild type) genotypes, that indicates a negative prognosis in the case when mutations are present. Currently, there are no registered targeted drugs for carriers of the KRAS and NRAS genes mutations, however, preparations based on small molecules are under way. The gold standard for detecting mutations in the KRAS and NRAS genes is the analysis of the biopsy material in paraffin blocks. However, this method has significant limitations that can be circumvented by the analysis of circulating tumor DNA — a promising new method in the diagnosis of colorectal cancer.

Journal of Clinical Practice. 2021;12(1):66-71
pages 66-71 views

Bacterial meningitis imaging in children

Marchenko N.V., Voitenkov V.B., Skripchenko N.V., Dubitsky D.L., Bedova M.A., Ovchinnikov A.S., Churkina D.N.


In this review, we provide the data on the modern use of different MRI modalities and computer tomography (CT) as diagnostic and prognostic tools for meningitis of various etiology, first of all, bacterial purulent meningitis. Each of these techniques has its own field of application depending on the stage of the disease and the patient’s condition (necessity of intensive care procedures, ventilation support). The opinions on the diagnostic value of CT and structural MRI data differ and depend on the etiology and phase of the inflammatory process. In the recent years, the techniques of multiparametric MRI are widely implemented in the practice. Beside structural MRI, they include diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI) and MR spectroscopy (MRS), as well as studies with artificial contrast; there are some reports that these modalities are more effective as a diagnostic tool in meningitis. Thus, the use of multiparametric MRI techniques and CT with contrast is promising and justified for the diagnostics of patients with bacterial purulent meningitis from the viewpoint of enhanced sensitivity.

Journal of Clinical Practice. 2021;12(1):72-81
pages 72-81 views

Additional diagnostic capabilities in the practice of a PAP-test using liquid-based cytology

Aksamentov A.K., Melnikova N.V., Kolyshkina N.A., Kucherova O.N., Baklaushev V.P.


The role of oncogenic strains of human papillomavirus in the development of cervical cancer is currently not in doubt. In cervical cancer screening, a co-testing strategy is used, in which cytology and HPV testing are performed. When performing a cytological examination by liquid-based cytology, it is possible to conduct additional diagnostic studies that can be used to more effectively sort patients in order to optimize the volume of diagnostic and therapeutic measures. The article highlights the possibilities of diagnostic tests based on the assessment of microRNA and mRNA expression, as well as tests based on the analysis of DNA methylation from the cytological material. The introduction of new molecular genetic predictors of the cervical cancer development into clinical practice can increase the effectiveness of currently used screening programs.

Journal of Clinical Practice. 2021;12(1):82-89
pages 82-89 views

Application of additive 3D printing technologies in neurosurgery, vertebrology and traumatology and orthopedics

Yarikov A.V., Gorbatov R.O., Denisov A.A., Smirnov I.I., Fraerman A.P., Sosnin A.G., Perlmutter O.A., Kalinkin A.A.


Additive technologies are now widely used in various fields of clinical medicine. In particular, 3D printing is widely used in neurosurgery, vertebrology and traumatology-orthopedics. The article describes in detail the basic principles of medical 3D printing. The modern classification of 3D printers is presented based on the following principles of printing: FDM, SLA, SLS and others. The main advantages and disadvantages of the above-mentioned 3D printers and the areas of clinical medicine in which they are used are described. Further in the review, the authors discuss the experience with 3D printing applications, based on the data of the modern scientific literature. A special attention is paid to the use of 3D printing in the manufacture of individual implants for cranioplasty. 3D printing technologies in reconstructive neurosurgery make it possible to create high-precision implants, reduce the time of surgical intervention and improve the aesthetic effect of the operation. The article also presents the data of the modern literature on the use of 3D printing in vertebrology, where a special role is given to the use of guides for the installation of transpedicular screws and the use of individual lordosing cages. The use of individual guides, especially for severe spinal deformities, reduces the risk of metal structure malposition and the duration of surgical intervention. This technique is also widely used in traumatology and orthopedics, where individual implants made of titanium, a bone-substituting material, are created using 3D printing, thanks to which it is possible to replace bone defects of any shape, complexity and size and create hybrid exoprostheses. The role of 3D modeling and 3D printing in the training of medical personnel at the present stage is described. In conclusion, the authors present their experience of using 3D modeling and 3D printing in reconstructive neurosurgery and vertebrology.

Journal of Clinical Practice. 2021;12(1):90-104
pages 90-104 views

Case report

Ipsilateral block or can a single ECGbe used for the diagnosis?

Konev A.V., Simonenko E.V., Khimiy O.V., Korolev S.V., Dundua D.P.


Background: Pre-excitation syndrome (premature excitation of the ventricles) is a congenital anomaly in the structure of the cardiac conduction system and consists in the presence of an additional atrioventricular connection. The possibility to assume the presence of pre-excitation syndrome accompanied by tachycardia based on an electrocardiogram provides a clue to the correct diagnosis and subsequent treatment of the patient. Clinical case description: A clinical case of a 56-year-old patient is presented, who was admitted to the FRCC of the FMBA of Russia in January, 2021 with paroxysms of previously undiagnosed tachycardia. During Holter monitoring, an episode of heart palpitations was recorded. When analyzing an ECG fragment, it was possible, by calculating the tachycardia cycle length, to suspect the presence of a latent ventricular pre-excitation syndrome, which was accompanied by the development of orthodromic atrioventricular reciprocal tachycardia with a bundle branch block on the side of the additional atrioventricular connection (ipsilateral block). The patient underwent endocardial electrophysiological examination to confirm the presence of the bundle, followed by the catheter treatment of the atrioventricular connection. A good postoperative clinical result was obtained. Conclusion: It is important to be able to make a differential diagnosis between the presence of a latent pre-excitation syndrome with the development of orthodromic atrioventricular reciprocal tachycardia with the bundle branch block on the side of the extra atrioventricular junction (ipsilateral block) and other supraventricular tachycardias with an aberration along one of the bundle branches, in order to determine the tactics of the patient management and to control the effectiveness of the treatment.

Journal of Clinical Practice. 2021;12(1):104-112
pages 104-112 views

A clinical case of a successful step-by-step treatment of a patient with a dissecting aneurysm of the ascending aorta involving the trunk of the left coronary artery

Bocharov A.V., Popov L.V.


Background: The presented clinical case shows a version of successful step-by-step medical care for a patient with a dissecting aneurysm of the ascending aorta involving the trunk of the left coronary artery in a vascular center without a cardiac surgical support. Clinical case description: The patient was admitted to the Kostroma Regional Vascular Center with the symptoms of Acute Coronary Syndrome. During the examination in the clinic, the diagnosis of acute coronary syndrome with ST segment elevation was confirmed, and a dissecting aneurysm of the ascending aorta was also revealed. According to emergency coronary angiography, the dissection of the left coronary artery trunk was visualized, and the left coronary artery trunk was successfully stented with a bare metal stent. Later, the patient was transferred to a federal center, where aortic prosthetic reconstruction was performed. Conclusion: In patients with a dissecting thoracic aortic aneurysm involving the trunk of the left coronary artery and acute myocardial damage, who are admitted to a vascular center without a cardiac surgery support, the following step-by-step treatment strategy is likely to be effective: stenting the trunk of the left coronary artery with a bare metal stent and a further transfer to a center of cardiac surgery for a surgical treatment.

Journal of Clinical Practice. 2021;12(1):113-118
pages 113-118 views

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