• No results found

A CLINICAL CASE OF SUCCESSFUL BALLON ANGIOPLASTY IN THE REMOTE PERIOD IN A MIDDLE-AGED PATIENT AFTER

N/A
N/A
Protected

Academic year: 2022

Share "A CLINICAL CASE OF SUCCESSFUL BALLON ANGIOPLASTY IN THE REMOTE PERIOD IN A MIDDLE-AGED PATIENT AFTER "

Copied!
38
0
0

Повний текст

(1)

V. N. KARAZIN KHARKIV NATIONAL UNIVERSITY

PROPAEDEUTICS OF INTERNAL MEDICINE AND PHYSICAL REHABILITATION

DEPARTMENT

A CLINICAL CASE OF SUCCESSFUL BALLON ANGIOPLASTY IN THE REMOTE PERIOD IN A MIDDLE-AGED PATIENT AFTER

LATE STENT RESTENOSIS

Speaker: student of IV course, gr.409, Roni Morani

Scientific supervisors: D. Y. Pavlova, Assistant Professor T. V. Zolotarova, Assistant Professor Head of department: M. S. Brynza, Candidate of Medicine

(2)

MYOCARDIAL REVASCULARIZATION AFTER ACUTE MYOCARDIAL INFARCTION

● Myocardial revascularization procedures represent important treatment options for patients with acute and chronic coronary artery disease (CAD).

● Acute myocardial infarction (MI) was identified nearly 50 years ago as a coronary occlusive event resulting from atherosclerotic plaque rupture and thrombosis. This mechanistic understanding was essential to the development of reperfusion therapy for treating ST-segment elevation MI (STEMI).

● The treatment of STEMI has advanced since the introduction of reperfusion therapies.

● Mechanical reperfusion with primary percutaneous coronary intervention is now the standard of care.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880555/

(3)

IN-STENT RESTENOSIS

● The introduction of bare metal stents (BMS) was a significant milestone in the evolution of percutaneous coronary intervention. Soon after it was apparent that these stents led to in-stent restenosis (ISR), which requires repeat revascularization.

● Restenosis is defined as a reduction in lumen diameter after percutaneous coronary intervention (PCI), either with or without stent implantation.

● In-stent restenosis currently defined as a >50% stenosis of a previously stented segment, occurs in 30% of all patients receiving BMS.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5107494/

(4)

BALLOON ANGIOPLASTY FOR THE TREATMENT OF CORONARY IN-STENT RESTENOSIS

Balloon angioplasty (BA) was one of the earliest strategies used in patients experiencing ISR. The procedure is technically straightforward and consistently associated with satisfactory acute results and a very low incidence of complications.

Currently available therapeutic modalities, such as drug-coated balloons (DCB) and drug-eluting stents (DES) provide the best clinical and angiographic results in patients with ISR. However, the field is rapidly evolving. Further studies are required to identify clinical and anatomic characteristics that may help to refine selection and tailor available therapeutic strategies to improve clinical outcomes.

https://www.sciencedirect.com/science/article/pii/S0735109714013540

(5)

OUR PATIENT PROFILE

•51 years old (01.06.1968)

•Male

•Retired

•Lives in a village

•Hospitalized on 18.10.18 to the cardiological

department of City Clinical Hospital № 8

(6)

COMPLAINTS

Main

• Disruptions of the heart beats and heart palpitations which are related to physical activity

• Shortness of breath when walking (observed during physical exertion, while ascending the staircase to the fifth floor), disappearing after the rest

• Unstable blood pressure (increasing of BP in the range of 160/90 mmHg – 180/100 mmHg, despite taking hypotensive drugs, –

Bicoprolol, Ramipril)

Additional:

Fatigue

General weakness

(7)

MEDICAL HISTORY 1.2

Hypertension for 10 years with the maximum blood pressure (BP) over 180/100 mm Hg

The usual BP is about 140/90 mm ​​Hg (antihypertensive drugs – Bisoprolol 5 mg, Ramipril 5 mg

Since 2009, the blood pressure measured noted to be consistently elevated in the range of 160/100 mmHg – 180/100 mmHg on three occasions

On August 18 2016 was diagnosed with Non-Q-wave myocardial infarction (left ventricular posterior wall myocardial infarction)

On September 7 2016 was performed coronary angiography and

heart catheterization

(8)

MEDICAL HISTORY 2.2

● On September 18 2016 was performed coronary angiography with implantation of two non–drug-eluting stents

● On February 2017 symptoms of progressive unstable angina, diagnosed in-stent restenosis, completed balloon angioplasty

● On October 2018 admitted to the cardiological department with complaints:

palpitations that were connected with physical exercises; breathlessness while ascending to the fifth floor

● Hospitalized with the diagnoses: Ischemic Heart Disease. Postinfarction (posterior STEMI of LV 18.08.16) cardiosclerosis. Arterial Hypertension, stage III, grade 2, high risk. Chronic heart failure, NYHA class II, stage С, with preserved EF (50%). Patient hospitalized to the cardiological department of CCH №8 for examination and correction of the treatment.

(9)

MEDICAL HISTORY - CORONARY ANGIOGRAPHY

A - Angiography showed the left anterior descending coronary artery stenosis (50%) B - the left circumflex artery occlusion of the distal segment

C - occlusion of the obtuse marginal branch

A

C B

7.08.16 27.09.16

D - During angiography performed recanalization of occlusion of the distal segment with Ryujin balloon 1.5 cm * 15 mm with implantation of two Bare – Metal Stents: Chroma 2.25 * 14 mm and Chroma 2.75 * 24 mm.

D

(10)

MEDICAL HISTORY - BALLOON ANGIOPLASTY (17.02.17)

Patient admitted to the cardiological department with symptoms of progressive unstable angina.

The Coronary Angiography revealed restenosis of a stented segment to the level of subocclusion, with chronic occlusion of the obtuse marginal branch. The right coronary artery was without significant hemodynamic disturbances.

During angiography performed angioplasty of the restenosis with NC

Sprinter ballon 2.5 * 15 mm.

(11)

HISTORY OF LIFE

• Was born in a full family, developed according to age

• Denies tuberculosis, diabetes, malaria, viral hepatitis, sexually transmitted diseases and AIDS

• Denies allergic reactions to drugs

• Non-smoker

• Denies alcohol consumption

• Sedentary lifestyle

• Hasn’t checked his lipid and glucose profile over 6 months

• Hereditary - no family history of cardiovascular disease

(12)

OBJECTIVE STATE: 1.2

• The general condition is satisfactory, consciousness is clear, emotionally stable, optimistic mood

• Hypersthenic, height 176 cm, weight 80 kg, BMI = 25.8 kg / m

2

, waist-to-hip ratio 0,90

• Skin, visible mucous membranes are pale pink and clean

• Peripheral lymph nodes are not palpable

• The thyroid is not palpable

(13)

OBJECTIVE STATE: 2.2

• Respiratory System: Pulmonary percussion – resonant sound, auscultation - vesicular breathing , no adventitious sounds

• Cardiovascular system: Heart borders extended to the left on 1,5 cm of midclavicular line, HR =76 bpm, regular. Ps= 76 bpm. No pulse deficiency

• Heart sounds are muted, accent of the II tone above the aorta.

• BP dextr = BPsin= 140/80 mm Hg (on the background of antihypertensive therapy)

• Gastrointestinal system: Abdomen is soft, painless, symmetrical, no discrepancies of the abdominal muscles.

• No visible peristalsis.

• Liver edge is smooth, painless , palpated 2 cm below the costal arch.

• Spleen and pancreas are not palpable

• No pitting oedema

(14)

EXAMINATION

Examination, completed in the hospital

• General blood test

• General urine test

• Biochemical blood test (Liver and renal function tests)

• Blood lipid spectrum

• Blood glucose level

• Electrocardiography

• Echocardiography

• 24 hours electrocardiography monitoring

• Stress test ( Cycle Ergometer test)

Recommended additional examination

Blood glucose level (Hb A1c)

Random glucose test

Blood electrolytes (K, Na)

Cardiologist consultation

Endocrinologist consultation

Ultrasonography of the abdomen (liver, gallbladder, pancreas, kidneys)

This tests wasn’t completed for financial reasons.

(15)

COMPLETE BLOOD TEST (19.10.18)

MEASURE RESULT RATE

Hemoglobin 154 M 130 - 160 g / l

Erythrocytes 5.04 M 4.0-5.0 T / l

Color index 1.06 0,85 – 1,15

Leukocytes 6.9 4,0 – 9,0 g/L

ESR 11 M 2-12 mm/h

Platelets 260 160-320 g/L

Band Neutrophils 1 1-6 %

Segmented Neutrophils 52 47-72 %

Eosinophils 1 0,5-5,0%

Basophils 0 1-1,0 %

Monocytes 3 3-11 %

Lymphocytes 43 19-37%

Conclusion: erythrocytosis

http://www.endmemo.com/medical/unitconvert/Dimethadione.php

(16)

GENERAL URINE TEST (19.10.18)

MEASURE RESULT NORMAL RANGE

SPECIFIC GRAVITY 1.012 1,001-1,040

REACTION 6,8 5,0-7,0

PROTEIN 0.020 to 0.033 g / l

GLUCOSE 0 Absent

LEUCOCYTES 1-2 6-8

EPITHELIUM TRANSITION Not detected Not detected

BACTERIA Not detected Not detected

Conclusion: normal

http://www.endmemo.com/medical/unitconvert/Dimethadione.php

(17)

BIOCHEMICAL BLOOD TEST (19.10.18)

MEASURE RESULT NORMAL RANGE

AsAt 27,8 <37 u/L

AlAt 60 <41 u/L

Fasting glucose 6,2 4,2-6,1 mmol/l

Creatinine 91,5 80-115 mcmol/L

Conclusion: elevated transaminases, hyperglycemia.

http://www.endmemo.com/medical/unitconvert/Dimethadione.php

GLOMERULAR FILTRATION RATE

RESULT NORMAL RANGE

GFR (Cockroft - Gault) 85.4 >90 ml/min/1.73m2

GFR (CKD-EPI) 83.2 >90 ml/min/1.73m2

GFR (MDRD) 81 >90 ml/min/1.73m2

Conclusion: According to GFR level, mildly reduced kidney function.

(18)

BLOOD LIPID SPECTRUM (19.10.18)

MEASURE RESULT RATE

Total Cholesterol 3,7 ≤ 5,2 mmol / l (<4,5)

VLDL 0,97 <1,0 mmol / l

LDL 1,92 <3,5 mmol / l

HDL- cholesterol levels 0,81 >0,9 mmol / l

Triglycerides 2,13 ≤2,3 mmol / l

Coefficient of atherogenicity 3,57 to 3,0 mmol/l

Conclusion: increased coefficient of atherogenicity due to the level of HDL

http://eurheartj.oxfordjournals.org/content/ehj/34/39/3035.full.pdf

(19)

ECG (18.10.18)

Result: sinus

rhythm, normal heart axis, with heart rate 54 bpm. Posterior wall repolarization interruption.

(20)

24 HOURS ELECTROCARDIOGRAPHY MONITORING (18.10.18)

Result: during 24-hours monitoring registered sinus rhythm, supraventricular premature contractions (total 210); short supraventricular tachycardia episodes;

monomorphic ventricular premature contractions (total 10). Daily heart rate - 55 beats/min (bpm), night heart rate - 55 beats/min (bpm).

(21)

Principles of diagnostic testing

https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Stable-Coronary-Artery-Disease-Management-of

(22)

CYCLE ERGOMETER STRESS TESTING FOR IDENTIFICATION OF SIGNIFICANT CORONARY ARTERY DISEASE (19.10.18)

• The bicycle ergometer test was carried out according to the incremental workloads calibrated in watts (W). The protocol started with a power output of 10W/minutes, followed by increases of 25 W/min. every 3 min.

The test was negative. Stopped after reaching the 150 W/min, the appearance of chest pain, heavy chest pressure, difficulty in breathing. The duration of the last step – 1 min. 30 sec.

• After stopping the test ECG showed ST segment without specific changes, registered infrequent ventricular extrasystoles without signs of coronary insufficiency, blood pressure - 210/100 mmHg, heart rate - 110 beats/min (bpm).

• Period of restitution was without specific features. Blood pressure recovered in 5 min. to 120/80 mmHg, chest pain relieved in 2 min.

(23)

ECHOCARDIOGRAPHY:1.2 (23.10.18)

Name Result Normal

1) Aorta 37 mm. 20-37 mm

2) Aortic Valve Opening 18 mm 17-26 mm

3) Left Atrium Antero-posterior size: 50 mm To 38 mm 4) Mitral Valve No regurgitation

5) Posterior wall of the LV

11 mm. Contraction – normokinetic. 6-11 mm

6) LV end-diastolic diameter

58 mm 46-57 mm

7) LV end-systolic diameter

43 mm 31 - 43 mm

https://www.asecho.org/wp-content/uploads/2015/01/ChamberQuantification2015.pdf

(24)

ECHOCARDIOGRAPHY:2.2

Name Result Normal

8) Interventricular septum 11 mm 6-11 mm

9) Right Ventricle D.: 24 mm D.: (9-26 mm). Thickness of the wall 3-6 mm

10) Right Atrium 38 mm <44 mm

11) Tricuspid Valve No regurgitation

10)Ejection Fraction 50% 55-78%

Conclusion: sclerotic changes of aortic walls, aortic valve.

Dilation of the left ventricle and atrium. Left ventricular hypertrophy.

https://www.asecho.org/wp-content/uploads/2015/01/ChamberQuantification2015.pdf

(25)

BASIC CLINICAL SYNDROMES

• Atherosclerosis (sclerotic changes of aortic valve, mild atherosclerotic aortic stenosis)*

• Arterial hypertension *

• Arrhythmias (permanent (constant) AF)

• Heart failure

• Dyslipidemia*

• Hypertensive heart (LVH, atrial enlargement, increased diastolic stiffness)*

• Hepatomegaly, liver steatosis

• Erythrocytosis, hemoconcentration

• Hyperglycemia / glycosuria syndrome*

• Obesity: BMI = 25.8 kg / m2, waist-to-hip ratio 0,90*

• * - features of metabolic syndrome

(26)

The clinical diagnosis according to current

classifications

(27)

Weight categories

BMI

(kg/m2) Underweight <18.5 Healthy

weight

18.5-24.9 Overweight 25-29.9 Obese 30-34.9 Severely

Obese

35-39.9 Morbidly

Obese

>40

CATEGORIES WAIST-TO-HIP RATIO

Health risk Men

Low 0.80 or lower

Moderate 0.81-0.85

High >0.86

CLASSIFICATION OF OVERWEIGHT AND OBESITY AND WAIST-TO-HIP RATIO

http://www.bmi-calculator.net/waist-to-hip-ratio-calculator/

(28)

DEFINITIONS AND CLASSIFICATION OF OFFICE BLOOD PRESSURE LEVELS (MMHG)

Category Systolic Diastoli c

Optimal <120 and <80 Normal 120-129 and/o

r

80-84

High normal 130-139 and/o r

85-89

Grade 1 hypertension

140-159 and/o r

90-99

Grade 2 hypertension

160-179 and/o r

100-109

Grade 3 hypertension

≥180 and/o r

≥110

Isolated systolic hypertension

≥140 and <90

http://www.esh2013.org/wordpress/wp-content/uploads/2013/06/ESC-ESH-Guidelines-2013.pdf Stage The degree of target organ damage

I Objective changes in the target organs are absent

II There is objective evidence of target organ damage without symptoms with their hand or dysfunction:

Left ventricular hypertrophy (on ECG, ultrasound, Ro) Generalized narrowing of retinal arteries

Microalbuminuria and / or a small increase in serum creatinine (y m. - 115 - 133 mmol / L at x. - 107 - 124 mmol / l) Carotid artery disease - a thickening of the intima-media> 0.9 mm or the presence of atherosclerotic plaques

III There is objective evidence of target organ damage with symptoms from their side and impaired heart - myocardial infarction, heart failure II A - III stage; brain - stroke, transient ischemic attack, acute hypertensive encephalopathy, vascular dementia; fundus - hemorrhage and retinal exudates with papilledema the optic nerve or without; kidney - concentration of plasma creatinine in males> 133 umol / L, y Women> 124; vessels - dissecting aortic aneurysm; peripheral arterial occlusion

Functional capacity Objective Assessment

Class I - No symptoms and no limitation in ordinary physical

activity, e.g. shortness of breath when walking, climbing stairs etc. Class A. No objective evidence of cardiovascular disease.

Class II - Mild symptoms (mild shortness of breath and/or

angina) and slight limitation during ordinary activity. Class B. Objective evidence of minimal cardiovascular disease.

Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20—100 m).Comfortable only at rest.

Class C. Objective evidence of moderately severe cardiovascular disease.

Class IV - Severe limitations. Experiences symptoms even while at

rest. Mostly bedbound patients. Class D. Objective evidence of severe cardiovascular disease.

THE NEW YORK HEART ASSOCIATION (NYHA) FUNCTIONAL CLASSIFICATION (FUNCTIONAL CAPACITY) OF CHF

AMERICAN HEART ASSOCIATION HEART FAILURE STAGES

(29)

COMPLETE DIAGNOSIS OF OUR PATIENT:

OUR CLINICAL DIAGNOSIS Main:

ISCHAEMIC HEART DISEASE. POSTINFARCTION (POSTERIAL STEMI OF LV 18.08.16) CARDIOSCLEROSIS.

7.08.16 CORONARY ANGIOGRAPHY, 27.09.16 CORONARY ARTERY STENTING WITH TWO BARE-METAL STENTS, 17.02.17 BALLOON ANGIOPLASTY AFTER STENT RESTENOSIS.

SYSTEMIC ATHEROSCLEROSIS

(ATHEROSCLEROSIS OF THE AORTA)

ESSENTIAL ARTERIAL HYPERTENSION STAGE III, 2 GRADE. HYPERTENSIVE HEART (LVH)

CHRONIC HEART FAILURE WITH PRESERVED LEFT VENTRICLE EJECTION FRACTION ( EF- 50%), II CLASS, STAGE C NYHA.

VERY HIGH ADDED TOTAL CV RISK Co-morbidity: Pre- diabetes?

HEALTH FACILITY DIAGNOSIS Main:

ISCHAEMIC HEART DISEASE. ANGINA PECTORIS CLASS III.

POSTINFARCTION (POSTERIAL STEMI OF LV 18.08.16) CARDIOSCLEROSIS.

SYSTEMIC ATHEROSCLEROSIS (ATHEROSCLEROSIS OF THE AORTA)

ARTERIAL HYPERTENSION STAGE III, 3 GRADE

HYPERTENSIVE HEART (LVH)

(30)

TREATMENT

Lifestyle modification

Medical intervention

(31)

THERAPEUTIC LIFESTYLE CHANGES

PARAMETER TREATMENT GOAL

Weight loss

(for overweight and obese patients) Reduce by 5% to 10%

Physical activity

• At least 150 minutes of moderate-intensity physical activity (for example, 30 minutes, 5 days a week),

or

• At least 75 minutes of vigorous-intensity physical activity (for example, 25 minutes, 3 days a week); or

• A combination of moderate- and vigorous-intensity aerobic activity, and

• At least 2 days of moderate- to high-intensity muscle- strengthening activities (such as resistance

weight training) for additional health benefits

Diet

Vegetables, fruits, and whole grains

Legumes and nuts

Low-fat dairy products

Low-fat poultry (without the skin)

Fish and seafood

Nontropical vegetable oils

https://www.heart.org/-/media/files/health-topics/cholesterol/chlstrmngmntgd_181110.pdf

(32)

TREATMENT STRATEGY 1.2.

Our goals:

BP target – 130-139/85-89 mm Hg

n LDL-C target of 1.8 mmol/L (70 mg/dL)

Glycated Hemoglobin (HbA1c) to ,7.0% (53 mmol/mol)

According to the ESC Clinical Practice Guidelines 2013, Management of Stable Coronary Artery Disease

https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Stable-Coronary-Artery-Disease-Management-of

(33)

HEALTH FACILITY TREATMENT

Drug therapy

Bisoprolol 5 mg in the morning

Enalapril 5 mg in the morning

Aspirin 100 mg in the evening

Clopidogrel 75 mg in the evening

Atorvastatin 40 mg in the evening IV therapy

Meldonium 500mg / 5.0 ml, N10

RECOMMENDED TREATMENT

Drug therapy

Angiotensin-converting enzyme (ACE) inhibitor-Ramipril 5 mg in the morning

Diuretic – Eplerenone 25 mg, in the morning

Β- blocker-Bisoprolol 5 mg in the morning (target HR – 60 b/m)

Antiplatelet therapy - Aspirin 100 mg in the evening

Antiplatelet agent - Clopidogrel 75 mg in the evening

Statin- Rosuvastatin 20 mg in the evening

(34)

CONTROL OF COMPLIANCE TO MEDICAL

RECOMMENDATIONS (diet, weight, physical activity,

drug treatment) !

(35)

RECOMMENDATIONS FOR FURTHER EXAMINATION

• Exercise ECG

• 24h-ECG monitoring

• Daily glycemic profile, Glucose tolerance test, HbA1C, consultation of Endocrinologist

• Echocardiography for evaluation of diastolic function of LV

• Lipid profile (LDL), ALT (liver)

https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines

(36)

PROGNOSIS

•Prognosis for life - non-compliance to doctor's appointments – non-

satisfactory

•The prognosis for recovery -

unfavorable

(37)

Conclusions

In our clinical case, according to the result of cardiac stress test, when veloergometer cycle test showed no signs of myocardial ischemia, balloon angioplasty has proven to be an effective method of In-stent restenosis treatment.

Considering that Diabetes mellitus has a role in foster the In-stent restenosis process, further diagnostic recommended: HbA1c, fasting plasma glucose and postprandial glucose level control, glucose tolerance test.

To clarify the segmental heart contractility, we recommend additionally a Stress-echo test and Speckle tracking echocardiography.

Repeat Coronarography in case of cardiac ischemia signs.

(38)

THANK YOU FOR

ATTENTION!

Посилання

СУПУТНІ ДОКУМЕНТИ

 This primary syndromic diagnosis requires either empirical symptomatic or anti-Helicobacter pylori treatment, or further examination of the patient, especially

For example, in Ukraine, use of physical restraint and (or) isolation in the provision of psychiatric care to convicts suf- fering from mental disorders is carried out in accordance

(2015) aimed to elucidate the positive effects of case-based learning compared to a didactic lecture on pharmacology and to assess students' perceptions of CBL. These studies

To describe clinical case of the basal cell carcinoma treatment, determine personalized diagnostic algorithm of the patient management with further selection of the therapy

All pregnant women with measles had epidemiological history of contact with measles patients and in all cases diagnosis of measles was confirmed by detection measles IgM in

During the study, patients were examined twice (at the beginning of treatment and after 10-12 days (at the end of therapeutic TMS sessions) according to the following scheme:

The aim is to familiarize practitioners with the initial clinical manifestations of acute myeloid leukemia and its diagnosis in a patient with a past medical history of

Postnatal diagnosis of OI is based on data obtained from the collection of anamnestic reports, clinical manifestations and results of radiography (osteopenia, osteoporosis,

entrepreneurial type – critical and strategic thinking, leadership and partnership, digital competence, and the like; – the introduction of distance learning as a self-sufficient

To determine the possibilities and clinical effectiveness of combined approaches in the treatment of cardiac achalasia using endoscopic pneumocardiodilation

3 of the clinical base of the Phthisiology and Pulmonology Department of ZSMU (Zaporizhzhia State Medical University) in the Municipal Institution “Zaporizhzhia Regional TB

However, the European Convention on Human Rights is still a source of the EU law, as the EU values set by the Founding Treaties have a lot in common with the values set by

For this, we carried out a retrospective clinical and statistical analysis of 49 case histories and childbirth histories, newborns histories in the maternity hospital №

• This clinical case is an illustration of the fact that infectious bacterial diseases play a key role in the pathogenesis of reactive arthritis, and repeated bacterial

The patient was hospitalized in the Pulmonary Tuberculosis Department No 3 (Department of Resistant Tuberculosis) of the Clinical Site of Phthisiology and Pulmonology Department

• Another factors contributing to myocardial ischemia are associated with the increasing left ventricular diastolic dysfunction associated with hypertension, and also with

The Duke diagnostic criteria Major blood culture criteria for IE include the following:.  Two blood cultures positive for organisms typically found in patients

The aim: To determine the structure of acute injuries of temporary and permanent frontal teeth in children, to analyze the applied diagnostic and treatment measures for acute

Sialolithiasis is one of the most common and extensively obstructive disorders of the major salivary glands. Here, we report 3 cases of sialolithiasis in the submandibular sali-

The analysis of the causes of increased hydraulic energy losses has allowed to solve the problem of improving the working flow, improving operational energy cavitation

Adaptive machining when programming the milling operations of details contours on a CNC machine in the case of a virtual workpiece basing is performed as a result of minimax

Remember what, according to the theory, the rereading test would predict: canonical texts (in our case Texts 2 and 3) should be evaluated higher on a second reading, while

Based on above assumptions, force acting on a test charge in case of &#34;ionic&#34; crystal will be determinated by forces from positive and negative immobile ions, in case