Vol 12, No 4 (2021)

Original Research

The effectiveness of dexmedetomidine in patients with severe COVID-19

Andreychenko S.A., Bychinin M.V., Mandel I.A., Klypa T.V.

Abstract

Background: Mortality in patients with severe COVID-19 remains high. Finding therapies that can improve the outcome in these patients is an urgent task.

Aims: To evaluate the clinical efficacy of dexmedetomidine in the complex treatment of patients with a severe course of COVID-19.

Methods: The retrospective study included 50 adult patients with severe COVID-19 admitted to the intensive care unit (ICU). The primary outcome of the study was the incidence of delirium. The secondary results of the study were the dynamics of gas exchange indicators (PaO2 and PaCO2) and inflammatory markers (C-reactive protein, CRP; procalcitonin, lymphocyte count, and neutrophil-lymphocyte ratio, NLR) on day 3 and day 5 of the treatment, as well as the duration of mechanical ventilation (MV), length of stay (LOS) in the ICU and in the hospital and mortality.

Results: The incidence of delirium did not differ between the dexmedetomidine group and the control group (41 and 48%, respectively; p=0.661). The LOS in the ICU and in the hospital, as well as the MV duration, was comparable between the groups. However, the hospital mortality in the dexmedetomidine treatment group was lower than that in the control group (10.3% and 42.9%, respectively; p=0.008). The addition of dexmedetomidine to the therapy complex did not affect the blood gas composition but contributed to the increase in the number of lymphocytes (p=0.006) and to the NLS decrease (p=0.002) by the fifth day of treatment. At the same time, no significant changes in the CRP and procalcitonin levels were observed.

Conclusion: In the treatment group, the mortality was statistically significantly lower than it was in the control group. At the same time, the use of dexmedetomidine did not reduce the incidence of delirium, the length of stay in the ICU and in the hospital, and the duration of mechanical ventilation in patients with severe COVID-19. The revealed relationship between the use of dexmedetomidine and NLR and the number of lymphocytes suggests an immune-mediated effect on the outcome in this category of patients. Prospective randomized trials are needed to confirm the beneficial effects of dexmedetomidine on the immune system and mortality.

Journal of Clinical Practice. 2021;12(4):5-11
pages 5-11 views

Targeted walking training of patients in the early recovery period of cerebral stroke (preliminary research)

Skvortsov D.V., Kaurkin S.N., Ivanova G.E., Polyaev B.B., Bulatova M.A.

Abstract

Background: Currently, training of the gait function for patients with cerebral stroke using the biofeedback technology is an independent, effective, and promising method. The most common training and exposure parameters are the gait speed, cycle length, and cadence. However, the application of basic and more complex types of selective training using wearable sensor technology is rare due to the technological complexity of their use for biofeedback.

Aims: To study the possibility of using the biofeedback training technology with a targeted effect on one of the basic parameters characterizing the symmetry of walking, the duration of the support period, in patients in the early recovery period of cerebral stroke.

Methods: We examined 12 patients who underwent a course of biofeedback training to harmonize the period of support during the early recovery period of hemispheric cerebral stroke in the middle cerebral artery basin. The biomechanics of voluntary walking was investigated before and after the training. The spatio-temporal parameters of walking, kinematics of movements in the hip, knee, and ankle joints, and the maximum EMG amplitudes of the main muscle groups responsible for walking were recorded. The classical clinical scales were also used. The biofeedback training on a treadmill consisted of 10 sessions; the duration of the support period was the training parameter.

Results. As a result of the treatment, a significant improvement was noted according to the «Up&Go» clinical scale and Hauser’s walking index. The differences in the trained support phase after the treatment are not significant and demonstrate positive changes. The kinematics of movements in the joints also demonstrates relatively small, but significant changes for the knee joint. For the hip joint, no dynamics in the parameters’ values is observed; the joint function does not change significantly, and the amplitude asymmetry remains unchanged. For the knee joint, the greatest dynamics is observed for the main swing amplitude and its phase.

Conclusion: The study has shown that the purposeful biofeedback training of the gait function using the support period to reduce the functional asymmetry in this parameter, and also has a positive effect on other gait parameters.

Journal of Clinical Practice. 2021;12(4):12-22
pages 12-22 views

The use of the thrombodynamics test in the diagnostics of hemostasis disorders in patients with COVID-19 of varying severity

Krechetova L.V., Nechipurenko D.Y., Shpilyuk M.A., Beznoshchenko O.S., Beresneva E.A., Markelov M.I., Ivanets T.Y., Gavrilova T.Y., Kozachenko I.F., Esayan R.M., Pyregov A.V., Khachatryan N.A., Kodatskii D.S., Spiridonov I.S., Dolgushina N.V., Gorodnova E.A., Ataullakhanov F.I., Rumyantsev A.G., Degtyarev D.N.

Abstract

Background: At the present moment, an urgent and unresolved problem is the search for a method to diagnose disorders of the hemostasis system in patients with the new coronavirus infection. The integral tests, in particular, the thrombodynamics test, will presumably make it possible to monitor changes in blood clotting, and predict the course of the disease in patients with COVID-19.

Aims: To comparatively assess the plasma hemostasis parameters and results of the thrombodynamics test in patients with COVID-19 viral infection of different severity.

Methods: The study included 96 patients with a confirmed diagnosis of COVID-19, admitted to a hospital for infectious diseases on the base of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology, and Perinatology in the period from April 23, 2020, to June 20, 2020, and discharged at the end of treatment. SARS-CoV-2 was identified by PCR. The patients were stratified by the severity into 3 groups: mild course (n=25), moderate course (n=54), severe course (n=17). The diagnostics and treatment of patients were carried out in accordance with the Temporary Methodological Recommendations of the Ministry of Health of the Russian Federation for the prevention, diagnosis and treatment of the new coronavirus infection, versions 5, 6, 7. In the course of the treatment, the patients were assessed for APTT, prothrombin %, prothrombin time (PT) and thrombin time, fibrinogen, D-dimer, platelet count, and the thrombodynamic test parameters (V/Vi/Vst, Tlag, Cs, D).

Results: Significant differences were observed in the thrombin time, D-dimer, platelet count, and the thrombodynamic parameters of V/Vst, Cs, and D taken before admission and a week after admission. We found a relationship between the parameters of hemostasis (fibrinogen concentration, PT, prothrombin %, APTT, Tlag, D) and the duration of hospital stay. There was a positive relationship between the content of fibrinogen and D (r=0.6307, p <0.0001) and a strong positive relationship between PT and Tlag (r=0.7499, p <0.0001).

Conclusions: The thrombodynamics test can be recommended as a potential tool for a personalized approach to monitoring the hemostasis system and treating patients with COVID-19.

Journal of Clinical Practice. 2021;12(4):23-37
pages 23-37 views

Clinical characteristics of patients with chronic migraine, depending on their personality profile

Baiushkina L.I.

Abstract

Background: Chronic migraine is a highly disabling neurological disease that is difficult to treat. The success of the therapeutic management depends, in part, on the psychosocial and personal factors.

Aims: To evaluate the clinical characteristics of patients suffering from chronic migraine, depending on the prevailing coping strategy of the individual.

Methods: 104 patients with an established diagnosis of chronic migraine were examined, all of them underwent а clinical and neurological examination and questionnaire testing.

Results: In the studied group of patients, active behavioral coping strategies (a strategy for solving the problem and seeking a social support) prevailed, while passive coping was much less common. The patients with active coping strategies had the lowest level of comorbid psychoemotional disorders.

Conclusion: The patients with passive coping strategies had a shorter medical history and the least severe effect of migraine, but the frequency of headaches and time lost due to headaches for these patients were comparable to those for the patients with active coping strategies.

Journal of Clinical Practice. 2021;12(4):38-43
pages 38-43 views

The study of the efficiency of micropulse transscleral cyclophotocoagulation in the combined treatment of patients with secondary neovascular glaucoma

Sidorova A.V., Starostina A.V., Pecherskaia M.A., Khabazova M.R., Arisov A.A.

Abstract

Background: Neovascular glaucoma (NVG) is a highly refractory form, it is characterized by fast development and a high level of the intraocular pressure (IOP).

Aims: To evaluate the effectiveness of micropulse transscleral cyclophotocoagulation (mCPC) in the combined treatment of patients with secondary neovascular glaucoma.

Methods: The study included 32 patients (32 eyes) with secondary NVG as an outcome of diabetes mellitus and (or) thrombosis of the central retinal vein or its branches. The preoperative IOP averaged 38.8±8.8 mm Hg with the most intense hypotensive therapy. All the patients underwent mCPC. In the postoperative period, the patients were examined on the first day after the operation, then in 1 week, 1, 3, 6 months, 1 year after the operation.

Results: All the operations were performed without complications. Pain syndrome in all cases was stopped on the first day after surgery. Six patients had reactive hypertension on the first day, therefore, the hypotensive therapy was intensified. The IOP 1 week after mCPC was 20.9±7.9 mm Hg, after 1 month of observation — 23.7±6.0 mm Hg with the hypotensive therapy. 3–4 weeks post-surgery, six patients with the preserved visual function experienced a repeated IOP increase, and the Ahmed valve was implanted. 6 months after mCPC, the IOP level averaged 22.8±7.7 mm Hg with the hypotensive therapy. Against the background of the IOP compensation, anti-VEGF drugs were injected in 4 cases, followed by laser coagulation of the retina.

Conclusion: Application of mCPC in NVG glaucoma patients showed only a small number of postoperative complications. This method of laser treatment can be used in combination with panretinal laser coagulation before or after the surgery, including administration of anti-VEGF drugs before or after the surgery. In case of the IOP increase, mCPC may be repeated.

Journal of Clinical Practice. 2021;12(4):44-50
pages 44-50 views

Reviews

Regenerative rehabilitation of skeletal muscle damages

Sсherbak S.G., Makarenko S.V., Kamilova T.A., Golota A.S., Sarana A.M.

Abstract

The article is devoted to the analysis of the current state of regenerative and rehabilitative treatments of skeletal muscles, the possibilities of restoring the functioning of tissue lost due to aging, injuries or diseases. The study of the molecular genetic basis of mechanotransduction and mechanotherapy will allow the identification of genes and molecules, the expression levels of which can serve as biomarkers of the effectiveness of regenerative-rehabilitation measures. These mechanisms are potential therapeutic targets for stimulating of regeneration of skeletal muscles. The focus of the article is on the choice of an individual approach, both when conducting basic scientific research and developing rehabilitation programs. All this will significantly improve patient outcomes.

Journal of Clinical Practice. 2021;12(4):51-65
pages 51-65 views

Atrial fibrillation in patients with coronary heart disease: current state of the problem

Zotov A.S., Sakharov E.R., Korolev S.V., Drakina O.V., Khabazov R.I., Troitskiy A.V.

Abstract

Atrial fibrillation is one of the most common types of cardiac arrhythmia observed in clinical practice. Despite advances in the diagnosis and treatment, atrial fibrillation remains one of the leading causes of cardiovascular mortality and morbidity. In addition, atrial fibrillation is quite often combined with other pathologies of the cardiovascular system and is a marker of an unfavorable outcome. Several previous studies have demonstrated reduced survival in patients with coronary artery disease and atrial fibrillation who have not undergone surgery for arrhythmia. According to other data, the presence of preoperative atrial fibrillation among patients undergoing isolated coronary artery bypass grafting was associated with significantly higher rates of major postoperative complications. Nowadays, no one doubts the fact that atrial fibrillation during a coronary artery bypass surgery is a risk factor for increased hospital mortality, postoperative morbidity and leads to a decrease in the long-term survival. The studies confirm the necessity of surgical ablation for atrial fibrillation during coronary revascularization to reduce both short-term and long-term postoperative mortality and late complications.

Journal of Clinical Practice. 2021;12(4):66-74
pages 66-74 views

Immediately sequential bilateral cataract surgery: pros and cons

Pokrovsky D.F.

Abstract

This review presents the main pros and cons of immediately sequential bilateral cataract surgery versus delayed sequential bilateral cataract surgery. The main arguments against immediately sequential bilateral cataract surgery are the likelihood of postoperative bilateral endophthalmitis and refractive errors. At the same time, a careful selection of patients, implementation of safety recommendations and the use of intracameral antibiotics, combined with the improvement of formulas for calculating intraocular lenses, provide the advantages of immediately sequential bilateral cataract surgery associated with the rapid rehabilitation of patients after surgery and economic reasons.

Journal of Clinical Practice. 2021;12(4):75-79
pages 75-79 views

Clinical case

A clinical case of successful treatment of a giant serous endometrial carcinoma imitating ovarian cancer

Berishvili A.I., Ivanov Y.V., Lebedev D.P., Zabozlaev F.G., Kravchenko E.V., Klypa T.V., Kedrova A.G.

Abstract

Background: Giant tumors of the abdominal cavity, as a rule, occur in elderly patients with characteristic features and represent a serious problem in terms of choosing a radical method of therapy. Of particular difficulty are cases of giant serous endometrial cancer, requiring a differential diagnosis with ovarian cancer.

Clinical case description: A clinical case of giant serous endometrial cancer mimicking ovarian cancer in a 55-year-old woman is presented. The patient came to the oncology department with complaints of abdominal enlargement, difficulty breathing and bloody discharge from the genital tract. The examination revealed the following: a giant formation (40×65 cm), occupying the entire pelvic and the entire abdominal cavities, ascites, lesions of the retroperitoneal lymph nodes, and the greater omentum, an umbilical hernia. A chest CT showed multiple contrast-accumulating circular shadows of 3–13 mm (metastases). By the decision of the council, after the preliminary chemoembolization of both the uterine and ovarian arteries, a supravaginal amputation of the uterus with appendages was performed, along with the resection of the greater omentum, removal of the umbilical hernia with positioning a plastic mesh implant and excision of an excess skin flap. The histological examination of the intraoperative material made it possible to verify the diagnosis of a serous endometrial carcinoma with subtotal tumor necrosis, the myometrium invasion of more than a half of its thickness, with the egress to the perimetrium, metastatic lesions of both ovaries, the greater omentum, anterior abdominal wall. Stage T3b (FIGO IIIB). In the postoperative period, 6 courses of Paclitaxel / Carboplatin (AUC4-5) chemotherapy were carried out with a pronounced clinical effect. The patient was discharged in a satisfactory condition. The control PET-CT scan after the 6th chemotherapy course showed no pathology in the thoracic cavity, and no process progress in the abdominal cavity. Currently, the remission of the disease is 9 months.

Conclusion: An algorithm for the diagnostic measures aimed at making the correct diagnosis is presented, and the tactics of treating a patient with giant serous endometrial cancer is described.

Journal of Clinical Practice. 2021;12(4):80-85
pages 80-85 views

Influence of common zones of low-amplitude activity on the mechanism and treatment of atrial arrhythmias

Dedukh E.V., Artyukhina E.A.

Abstract

Background: The treatment of left atrial flutter is a problem that requires a deep understanding of the underlying complex mechanism of arrhythmia. Although a considerable experience exists already in understanding the mechanisms underlying atrial flutter after ablation or surgery, little is known about atypical forms of atrial flutter in patients who have not previously undergone ablation or other cardiac surgery.

Clinical case description: We present a clinical case of interventional treatment of a patient with atypical atrial flutter who had not previously undergone surgical or interventional heart surgery. This clinical observation demonstrates the role of common zones of low-amplitude activity on the mechanism and treatment of atrial arrhythmias. Widespread areas of low-amplitude activity in the left atrium can create barriers to the propagation of excitation, which can cause atypical atrial flutter.

Conclusion: When performing a surgical intervention, high-density mapping will help to visualize the mechanism of this arrhythmia. Understanding the mechanism of atypical atrial flutter will help to minimize the RF exposure during the treatment.

Journal of Clinical Practice. 2021;12(4):86-91
pages 86-91 views

Facet syndrome. Minimally invasive surgical treatment. Clinical case with a literature review

Potapov V.E., Sorokovikov V.A., Larionov S.N., Zhivotenko A.P.

Abstract

Background: Degenerative pathology of the facet joints of the lumbar spine remains a significant medical and social problem due to persistent pain syndrome, high incidence and disability rate.

Clinical case description: A patient complaining of pain and discomfort in the lumbosacral spine on the right, arising in the upright position, intensifying with bending and flexion-extension of the trunk, and periodically spreading to the right gluteal region and along the posterior surface of the thigh, was admitted to the neurosurgical department of the Irkutsk Scientific Center of Surgery and Traumatology. A surgical treatment was performed in the form of dereception of the LII–LIII, LIII–LIV, LIV–LV arch-process joints. In the postoperative period, the patient noted a decrease in the intensity of pain in the lumbosacral spine to 3 points by a visual analog scale and was discharged from the department on the 5th day after the surgery in a satisfactory condition.

Conclusion: Facet joint pathologies represent a most common nosological form of the degenerative-dystrophic process (spondyloarthrosis) and a potential source of pain with the formation of instability of the spinal motion segment and chronic pain syndrome. The complex anatomical and topographic relationships between the facet joints, intervertebral discs, and radicular nerves force clinicians to pay attention to the pathology of facet syndrome. Understanding the morphological, clinical, and radiological features of the course of the facet joint degeneration makes it possible to increase the diagnostic capabilities for detecting facet syndrome of the lumbar spine and effectively apply transcutaneous surgical technologies for the treatment of chronic pain syndromes.

Journal of Clinical Practice. 2021;12(4):92-99
pages 92-99 views

Discussion

A new classification of chronic postinfarction aneurysms of the left ventricle in patients with coronary artery disease

Bocharov A.V., Popov L.V., Mittsiev A.K., Lagkuev M.D.

Abstract

The article highlights the historical moments of how the concepts for the diagnosis and treatment of postinfarction aneurysms of the left ventricle were developed, and the possibilities of the main diagnostic methods. As a rule, patients with chronic postinfarction aneurysms of the left ventricle have severe damage to their coronary bed, requiring invasive correction (coronary artery stenting or coronary artery bypass grafting), which must be performed either before or during the intervention to eliminate the left ventricular aneurysm. A new classification of chronic postinfarction aneurysms of the left ventricle is proposed, which takes into account rather the type of myocardial blood supply and the severity of damage to the coronary bed, than the actual features of aneurysms. It determines the stages and tactics of treatment of patients with chronic postinfarction aneurysms of the left ventricle, focusing on the problem of coronary revascularization.

Journal of Clinical Practice. 2021;12(4):100-106
pages 100-106 views

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