Journal of Clinical Practice

BACKGROUND: Chest injuries account for a significant proportion of all combat trauma and are associated with mortality categorized as «preventable» or «potentially preventable». AIM: To characterize, through retrospective analysis, a cohort of casualties sustaining combat chest trauma from modern weaponry, and to compare the immediate outcomes of two surgical management strategies — comprehensive (Early Total Care) versus minimally sufficient surgical care (Early Appropriate Care) — delivered in a civilian hospital located in close proximity to the front line. Methods: A retrospective study of the immediate treatment outcomes of 304 wounded was conducted. Patient groups were stratified based on the nature of the wound (penetrating wound/blunt blast trauma) and the surgical strategy used (active in the initial period of treatment, followed by a transition to minimally adequate). Results: Penetrating mine-blast chest wounds were present in 187 patients, non-penetrating mine-blast chest trauma with pulmonary contusion — in 117. Multislice computed tomography (MSCT) was performed in all casualties. Patients with penetrating wounds were divided into two subgroups: subgroup I received comprehensive surgical care under the Early Total Care (ETC) principle (n=88; thoracotomy was performed in 36 (41%) patients, pleural drainage in 52 (59%)); subgroup II received minimally sufficient surgical care under the Early Appropriate Care (EAC) principle (n=99; initial pleural drainage was performed in all patients, and thoracotomy was required in only 3 (3%) cases during an observation period of 22.4±1.2 hours). Both subgroups were statistically comparable with respect to injury severity and hemothorax volume (p >0.05). The study demonstrated no difference in immediate outcomes between subgroups (including achievement of adequate oxygen saturation without respiratory support, hemodynamic stabilization with cessation of active hemorrhage, complete lung re-expansion, and absence of mediastinal shift on follow-up chest radiography). Mean time to evacuation to the next echelon of care was 28.1±2.5 hours in Subgroup I and 22.4±1.2 hours in Subgroup II (p=0.03). Among patients with blunt blast chest trauma, pleural drainage was required in 21 (17.9%) and thoracotomy in 1 (0.85%). No in-hospital deaths occurred in any group. CONCLUSION: Transitioning to a minimally sufficient surgical strategy for modern mine-blast chest trauma — specifically, initial pleural drainage with a large-bore silicone tube and thoracotomy reserved for strict indications — does not result in deterioration of immediate outcomes at the forward stage of care, enables a significant reduction in time spent at the front-line hospital, and facilitates earlier evacuation to rear medical facilities.

BACKGROUND: Evaluation of true venous invasion in pancreatic cancer using preoperative computed tomography data plays a key role in determining tumor resectability, choosing treatment strategies, and planning the extent of surgical intervention. With the widespread use of neoadjuvant chemotherapy, traditional computed tomography criteria for venous involvement developed for chemotherapy-naive patients may lose diagnostic reliability due to significant post-therapy fibrotic changes. AIM: To analyze the diagnostic capabilities of preoperative computed tomography in detecting true venous invasion of the portal system in patients with pancreatic cancer after neoadjuvant chemotherapy. METHODS: A retrospective analysis of 61 patients with pancreatic head cancer who underwent radical surgery was conducted. Patients were divided into two groups: 37 patients without preoperative drug therapy and 24 patients who received neoadjuvant polychemotherapy. Preoperative computed tomography data were used to assess the angle of circumferential tumor contact with the portal veins, the length of contact, and the nature of the vascular wall contour (the presence or absence of erosion). Histological examination of resected venous wall sections served as the reference method. RESULTS: Irregularity of the venous wall contour or tumor coverage of more than 180° of the main venous vessels were associated with a high rate of true venous invasion. However, the absence of erosion and contact of less than 180° did not exclude tumor growth into the venous wall. A significant proportion (24.3%) of patients classified as resectable ultimately had morphologically confirmed invasion. In patients after neoadjuvant chemotherapy, none of the pre- or post-treatment computed tomography findings reliably predicted the presence or absence of true venous invasion. Increasing the number of courses of neoadjuvant chemotherapy to more than five was associated with a significant reduction in the incidence of true venous invasion. CONCLUSION: After neoadjuvant chemotherapy, the diagnostic value of preoperative computed tomography in assessing true venous invasion in pancreatic cancer is significantly reduced. Even in the absence of vein contour irregularities and limited tumor-vessel contact, a clinically significant probability of tumor growth into the venous wall remains. On the other hand, in the presence of extensive contact and vascular wall irregularities, true vascular invasion may be absent. Computed tomography findings in the post-neoadjuvant group cannot be considered a reliable basis for refusing a patient surgical treatment.

BACKGROUND: Neurological improvement after acute ischemic stroke depends on multiple clinical and imaging factors, including baseline stroke severity, infarct volume, and the success of reperfusion therapy. Despite technically successful recanalization, 30–50% of patients show no meaningful clinical improvement. AIM: The aim of this study was to assess the association and prognostic significance of computed tomography perfusion parameters, as well as the use of intravenous thrombolysis and mechanical thrombectomy (taking into account the degree of recanalization on the TICI scale), with 24-hour NIHSS (National Institutes of Health Stroke Scale) dynamics in patients with acute ischemic stroke due to large vessel occlusion. METHODS: This retrospective single-center cohort included 52 patients with acute ischemic stroke caused by large vessel occlusion. Computed tomography perfusion data were analyzed using the ArchiMed PRO software. Ridge regression was applied to assess the effects of perfusion parameters, reperfusion therapies, and their characteristics on 24-hour change in NIHSS. RESULTS: The regression model that included clinical and perfusion parameters explained 44% of the variability in 24-hour change in NIHSS score. A lower baseline NIHSS score and the performance of mechanical thrombectomy were associated with a smaller decrease in NIHSS (p <0.05), whereas a higher degree of recanalization on the TICI scale (Thrombolysis in Cerebral Infarction) was associated with a greater decrease in NIHSS (p <0.05). For infarct core volume (trend toward worse outcome with larger volume), penumbra volume (trend toward greater improvement with larger volume), and the use of intravenous thrombolysis (trend toward greater improvement), directed but statistically non-significant associations were observed (in all three cases p >0.05). CONCLUSION: Successful recanalization is the leading predictor of short-term neurological improvement after acute ischemic stroke. Computed tomography perfusion parameters show trends consistent with previous literature; however, the limited statistical power of this cohort prevented these associations from reaching formal statistical significance.

BACKGROUND: Sarcopenia, the loss of muscle mass and strength, is a growing concern, especially in aging populations. Prediabetes, an intermediate state between normal glucose levels and diabetes, has been increasingly linked to muscle decline. AIM: to examine the association between prediabetes and sarcopenia risk. METHODS: A systematic search was conducted across databases including PubMed, ProQuest, Science Direct, Google Scholar, and the Cochrane Library to identify relevant studies on prediabetes and sarcopenia risk. Study quality was evaluated using the Newcastle-Ottawa Scale, and a meta-analysis was performed using Review Manager version 5.4. RESULTS: Five observational studies were included, with four undergoing quantitative synthesis. Results showed that individuals with prediabetes had a significantly higher likelihood of developing sarcopenia compared to those with normal glucose regulation (pooled OR 1.29, 95% CI 1.13–1.47; I² = 7%). CONCLUSION: Prediabetes was associated with increased odds of sarcopenia. However, these findings should be interpreted with caution due to the small number of studies. Despite these limitations, the results highlight the importance of early detection and management of prediabetes to reduce the risk of sarcopenia.

Over the past 15–20 years, pancreatic surgery centers worldwide have achieved fundamentally low in-hospital mortality rates of less than 1–3%. Several published data report near-zero mortality in key single-center series. These achievements allow us to rethink the concept of «zero mortality,» transforming it from a statistical abstraction into a tangible clinical goal, achieving the systematic development of modern surgical, anesthesiological, and organizational protocols. The concept of «zero mortality» in pancreaticoduodenectomy is achieved through the systematic organization of organizational, surgical, and functional protocols. The paradox of high frequency (up to 50%) with low mortality makes it less effective at preventing death after its onset (low failure-to-rescue rate, FTR). A key determinant of success is the centralization of operations in high-volume centers (>20 resections/year), which ensures a predictable flow of FTRs. Standardization of surgical technique, including the selection of a reproducible anastomosis method, minimization of blood loss, and a balanced assessment of resectability, reduces the risk of serious intraoperative complications. Implementation of early outcome algorithms based on a dynamic diptych of clinical and laboratory markers, with a focus on minimally invasive treatment methods (interventional radiology), improves outcomes. Rigorous multidisciplinary patient selection and growth acceleration protocols, effective even in high-risk patients, are essential elements. Systematic audit of mortality causes allows for the identification and prevention of preventive factors. Achieving the lowest possible mortality after pancreaticoduodenectomy is a feasible clinical goal. It is based on individual skill and a centralized, standardized, and multidisciplinary care system focused on minimizing FTR through early diagnosis and aggressive treatment.

Despite the widespread availability of serological tests and radiological imaging modalities, liver biopsy remains a commonly performed procedure employed in the diagnosis, prognostic assessment, and determination of further patient management strategies. The principal indications for biopsy include focal hepatic lesions of undetermined etiology, diffuse liver diseases, unexplained elevation of hepatic enzymes, and suspected transplant organ rejection; the main contraindications are thrombocytopenia, hypocoagulation, and ascites. Owing to technological advances and the availability of multiple biopsy techniques, all established contraindications have become relative in nature, while complication and mortality rates remain low. Traditionally, liver biopsy was performed using the blind percutaneous technique or under ultrasound guidance. Alternative methods now exist that allow adequate tissue sampling with a significantly reduced complication profile. Transluminal endoscopic procedures (natural orifice transluminal endoscopic surgery, NOTES) and robotic technologies represent promising avenues for further development; however, their widespread integration into clinical practice requires additional investigation. This literature review addresses the indications and contraindications for the procedure, the types of liver biopsy, their associated complications, and the principal strategies for enhancing procedural safety.

Rhegmatogenous retinal detachment is one of the leading causes of vision loss among the working-age population. Recent advances in ophthalmology include surgical techniques such as vitrectomy, scleral buckling, pneumatic retinopexy, intraoperative retinal photocoagulation, and retinal cryopexy, as well as their combinations. They have led to significant progress in the treatment of this condition; however, the desired anatomical and functional outcomes of surgical intervention are still unattainable in a number of cases. Characteristics of retinal detachment such as proliferative vitreoretinopathy, the extent of rhegmatogenous retinal detachment, the number and location of retinal breaks, structural changes, and macular involvement are being actively studied as factors determining the disease severity. To date, no standardized algorithms or objective criteria for preoperative assessment have been introduced into clinical practice to guide the choice of surgical treatment for rhegmatogenous retinal detachment. At the same time, a considerable number of studies have been devoted to the evaluation of various morphological changes in rhegmatogenous retinal detachment using optical coherence tomography (OCT). OCT focuses on the condition of the ellipsoid zone and external limiting membrane, outer retinal corrugations, intraretinal cystic cavities, macular thickness, and the length of the outer photoreceptor segments. These parameters are potential biomarkers of functional recovery after surgery. Systematization and analysis of research findings related to potential OCT biomarkers in retinal detachment may contribute to the development of new diagnostic approaches and surgical treatment strategies.

BACKGROUND: Mine-blast injuries often lead to complex combined vascular injuries of the extremities, resulting in the formation of false arterial aneurysms with traumatic arteriovenous fistulas. This presents a serious surgical challenge, especially in the area of post-traumatic fibrosis where open reconstructions are risky. The objective of this report is to describe a successful case and justify the tactics of a multi-stage endovascular treatment for a patient with a combined injury of the anterior tibial artery. CLINICAL CASE DESCRIPTION: We present a clinical case of a 27-year-old patient admitted 4 months after a mine-blast injury to the left lower leg. The diagnosis of a mine-blast injury with avulsion of the anterior tibial artery from the popliteal artery and the formation of a pseudoaneurysm with an arteriovenous fistula to the popliteal vein was confirmed by computed tomography angiography (CTA) and superselective angiography. Treatment included two sequential endovascular interventions: (1) endografting of the popliteal artery and the tibioperoneal trunk with embolization of the anterior tibial artery; (2) targeted embolization of the aneurysm’s feeding branches using microcoils. Follow-up examination 6 months after completion of treatment demonstrated patency of the popliteal artery and tibioperoneal trunk endografts, reduced blood flow in the aneurysmal cavity, and complete regression of clinical symptoms (edema and pain). CONCLUSION: Comprehensive staged endovascular management represents a highly effective and safe alternative to open surgery in the treatment of complex post-traumatic arteriovenous lesions. Computed tomography angiography and superselective angiography play a key role in preoperative planning, and dynamic surveillance is essential to determine indications for each subsequent stage.

BACKGROUND: Osmotic demyelination syndrome is an acutely developing, localized, symmetrical, non-inflammatory demyelination in the middle portion of the basis pontis (central pontine myelinolysis, CPM) or in the white matter of the cerebral hemispheres (extrapontine myelinolysis). Demyelination occurs in the most compactly arranged white matter as a result of cellular edema caused by an abrupt reversal of the osmotic gradient, the most common cause of which is rapid correction of chronic hyponatremia against a background of intracellular osmolyte depletion. The disease may also develop in association with other electrolyte and metabolic disturbances, including hypernatremia, hyper- or hypochloremia, hypokalemia, nutritional deficiency, intoxication, hyperglycemia, and hypertriglyceridemia, and may be a complication of diuretic or psychoactive drug use, hepatic and renal failure, and other conditions. Before the neuroimaging era, the disease was considered rare and was detected only at autopsy; however, after the introduction of MRI, it became evident that this syndrome is a relatively common complication in intensive care patients and may account for 0.23–2.5% of all cases of water–electrolyte disturbances, including asymptomatic or oligosymptomatic forms. CLINICAL CASE DESCRIPTION: We present a clinical case of CPM in a young female patient born in 1987 who, after an episode of severe nutritional disturbances leading to hyponatremia and its subsequent correction, developed pseudobulbar syndrome, tetraparesis, and ataxia. The diagnosis was confirmed by reconstruction of blood sodium dynamics from the discharge summary, which demonstrated excessively rapid correction of hyponatremia (initial hyponatremia 101.8 mmol/L; after 24 hours: 121 mmol/L; after 48 hours: 135.5 mmol/L), as well as by brain MRI findings showing a characteristic trident-shaped lesion in the central pons. Following treatment and rehabilitation, a significant regression of the neurological deficit was achieved, with complete functional recovery. CONCLUSION: This case demonstrates the importance for intensive care physicians and related specialists of recognizing the high risk of osmotic demyelination during rapid correction of water–electrolyte disturbances and of implementing timely prevention of this severe complication in accordance with current clinical guidelines.

BACKGROUND: Central retinal artery occlusion, like ischemic stroke, is a serious eye condition characterized by sudden and painless loss of vision in one eye. It is caused by thromboembolism, often secondary to atherosclerosis, and leads to retinal ischemia and necrosis. The visual prognosis for central retinal artery occlusion is poor, and there are no generally accepted treatment guidelines. In most cases, vision does not return, which highlights the need for emergency measures and a comprehensive therapy approach. CLINICAL CASE DESCRIPTION: A 71-year-old patient was admitted to the regional stroke response center of City Clinical Hospital No. 4 with sudden vision loss in his right eye and numbness in his left arm. The patient had hypertension and a long smoking history, which increased the risk of vascular complications. Examination revealed critical stenosis (up to 90%) of the right internal carotid artery, indicating a high risk of recurrent embolic events. Since intravenous thrombolysis was contraindicated because of late admission, the patient was initiated on dual-antiplatelet therapy with acetylsalicylic acid and clopidogrel to prevent further thrombosis. Ophthalmological examination confirmed central retinal artery occlusion with a characteristic cherry-red spot and ophthalmic artery non-perfusion. CONCLUSION: This case illustrates the importance of early diagnosis and an interdisciplinary approach to treatment of central retinal artery occlusion. Despite the poor visual prognosis, timely therapy and control of risk factors (hypertension, atherosclerosis) can reduce the possibility of recurrent vascular accidents. Optimal management includes emergency hospitalization, neuroimaging, and consultation with a vascular surgeon.