Leaving Moscow

Today I leave Moscow and fly back to Chicago (via Zurich). It has been a very educational and entertaining visit. I now look forward to our Russian friends' visit to Chicago in June!

(аэропорту Домодедово = Domodedovo Airport)

Day #10

Today we first visited the New Maiden monastery which is a historic monastery and cemetery near the center of Moscow  and near First Moscow State Medical University. Buried there are a number of famous 19th and 20th century doctors, writers, and politicians. Boris Yeltsin was buried there in 2007.

We then visited First Moscow State Medical University. This is the premier medical school and residency training program in Moscow. There are approximately 500+ students. Both of our hosts are graduates of this institution. Dimitry's son is currently a student there as well.

(Cord and Daria pose in the rain outside First Moscow State Medical University)

In Russia, prospective physicians enter a medical university for a 6 year training period (this includes what we consider undergraduate and medical school training combined). There are different spots available for enrollment for this training. Some are mostly merit based and others are government supported. Often students will pay money at the start of their training (either officially or unofficially) to reserve a spot at the university. Wealthy students can sometimes pay more to get a spot if they aren't otherwise admitted. Daria tells us that the system is being reformed to be closer to the way that medical university admissions are conducted in Europe, but that it still remains somewhat more complicated.

(Poster about diabetic food disease)

Daria describes that, like many physicians, she chose specialty training (medical endocrinology) at the completion of her medical university training (after 6 years). She then applied for endocrinology "residency" (which is equivalent to our subspecialty endocrine fellowship training). Surgery training would also be extra training (approximately 3 yrs for general surgery). There is no formal endocrine surgery program but surgeons can focus on this in some of the general training programs. Some surgeons will first complete medical endocrine training before pursuing surgery training but this is not common. Students who do not wish to specialize (the majority of students) usually complete around one year of post-graduate medical training in general medicine and then work in a general medicine clinic. Trainees who are interested in research and qualify, like Daria, can take extra time after their residency to pursue a PhD. 

At First Moscow State Medical University, Dr. Sturgeon gave a seminar on management of primary hyperparathyroidism to the residents and students. He was again introduced by Dr. Valentin Fadeyev, who is the head of the Department of Endocrinology. 

(Cord describes a focused parathyroid adenoma resection under regional anesthesia)

The lecture was received with great enthusiasm and there were excellent questions asked by those attending. Many of the students and residents speak english and they were eager to talk with Dr. Sturgeon after the seminar.

(Cord poses for a photo with Dr. Fadeyev and a number of the residents of First Moscow State Medical University)

Day #9

Today we began by observing a thyroidectomy surgery on the patient discussed yesterday (65yo woman, situs inversus with bilateral PTC by FNA). Dr Sturgeon learned the names of various surgical instruments in Russian.

While Cord observed the surgery, Daria introduced me to the head of diabetes education at Endocrinology Research Centre. We discussed their care of diabetes. As for other conditions at the Centre, patients come from all over the region to be evaluated and treatment.

Many patients come to the Centre specifically to be evaluated for starting insulin pump therapy or use of CGM. The government now has programs to pay for pumps but patients must still pay for their own infusion sets so most patients with pumps have some wealth. 

Other patients come to the Centre for evaluation because they have severe complications that need management (kidney, retinal, or diabetic foot disease) or for disgnosis of MODY or diabetic syndromes.

Patients come to the centre and stay generally for 1-2 weeks. There is no outpatient clinic at the Centre (since it is a specialty center). They provide extensive diabetes education programs to the patients. These are taught by the physicians as they do not have formal diabetes educators or advanced level nurses. They also start or adjust diabetes medications. They use almost entirely the same medications for diabetes (same brands of insulin, sulfonylureas, GLP-1 agonists, etc) but they are purchased directly by the patients (without prescription). 

(Advertisement pamphlet for metformin)

Later we returned to the lecture hall where Dr. Sturgeon delivered a seminar on management of advanced thyroid cancer. This was sponsored by the Moscow Medical Academy with funding by AstraZeneca. There was a simultaneous interpreter hired for this presentation (she informed Dr. Sturgeon that google translated his slide on FNA biopsy to the words "luxurious shard inspiration". Luckily, Dr. Sturgeon's live translation was far more effective and the seminar was received with great enthusiasm. 

At the lecture, Dr . Sturgeon was introduced by Dr. Valentin Fadeyev who is the head of Endocrinology at First Moscow State Medical University, the premier medical training program in Russia. Like Dr. Sturgeon, he is on the editorial board of the journal Thyroid:

http://www.liebertpub.com/editorialboard/thyroid-journal-program/625/

There was great interest in the lecture and the multiple questions continued for nearly 45 minutes after it was completed. 

We finished the day with excellent seats to watch the opera Boris Godunov at the historic Bolshoi Theatre.

Day #8

Today we had continued discussion of the similarities and differences in how medicine is practiced in the US and Russia.

(Cord and Daria)

(Cord and Dimitry)

The Endocrinology Research Centre is unique in the sense that it is an academic medical center with patients only in the specialty of endocrinology and related topics (example: diabetic foot and eye complications). Most patients in Russia are treated at their local hospital or clinic. Some of these are government funded and are associated with government funded pharmacies. These will provide life-saving medications to patients for free (example: insulin, prednisolone, some blood pressure medications) but only certain meds may be available (and they may change monthly). Other private clinics are associated with private pharmacies for which patients must pay out of pocket, usually. Patients do not need a prescription for the vast majority of medications. They can simply pay for them at a pharmacy. These include thyroid preparations (only LT4 is routinely available), OCPs, hydrocortisone and other corticosteroids, blood pressure meds, diabetes meds, and androgens. Viagra (and other ED drugs) and levothyroxine are frequently taken without indication from a doctor, our hosts tell us. Narcotics, seizure meds, psychotropic meds, and most benzodiazepines do require a prescription. Hospitals will not carry all medicines and sometimes have shortages. It is not uncommon for a patient's family to be asked to go to the pharmacy to buy a medication for a hospitalized patient. If no family is available, the physician may sometimes buy meds for their patients, though this would be rare. Medications are not generally as expensive as in the US.

Most physicians in the Endocrine Research Centre work between the hours of 9am-5pm, though the surgeons often start earlier and DM physicians often stay till 8pm. The facility is entirely inpatient (no formal clinic space) and patients stay in rooms of 4 with shared bathrooms at the end of the hall. Many conditions could be managed as an outpatient but patients travel from afar to visit the Centre so they will stay in the hospital for 1-3 weeks until their workup and management/surgery is complete. Some patients may come for simple follow up visits and/or labs and these patients are generally seen in the physicians office (no exam table and usually no exam of the patient). It is understood that patients will pay the physician (cash or a gift) for these exchanges. Physicians in Russia are not well paid and our guests tell us that most men cannot be medical doctors because they cannot support a family (indeed, most of the endocrinologists and trainees are women, the surgeons are mostly men).  Many physicians/surgeons work at other hospitals for consults/surgery in order to make more salary. They also see extra patients in their offices in order to collect extra money.

The Centre is staffed at night by one surgeon, one medical doctor, and one anesthesiologist. Since it is a endocrine specialty center, there are no emergency admissions or unexpected consults so the doctors frequently can sleep overnight (once critical duties are complete).

They have informal rounds (chart rounding) every morning and then see their patients on their own. Exams and labs are documented in an EMR but these are also printed for a paper chart record which is later stored (for at least 20 yrs). Conversations with patients (by phone or office visits) are generally not documented. They have formal rounds (at patients' bedside) once per week. Once per month they present interesting patients at clinical conference,

Daria's new job since completing her PhD dissertation research is at a local Moscow hospital. She is the first endocrinologist there and she is eager to improve their management of endocrine disorders. She says her job is 70% inpatient, 30% clinic (a few hours every day).

(Endocrinology Research Centre, front entrance)

This morning we observed a video assisted thorascopic resection of intrathymus parathyroid gland.

After, Dimitry and Daria presented the following cases and patients to us:

- 65yo woman, h/o DM on insulin and reportedly with situs inversus. Thyroid nodules were noted in 2000. Cytology by FNA first showed follicular neoplasia (at her local clinic ?) but repeat FNA showed PTC at the Centre. She has poorly controlled BP and diabetes so her surgery has been delayed but may proceed tomorrow morning.

Interestingly, she had (as part of pre-op workup) a CT abdomen and EGD. These are not routinely done but are done preop  very frequently in cases of symptoms or history of gastric ulcers ( which are common so they want to detect them before surgery). They also routinely perform lower extremity duplex ultrasound exams if there is evidence of venous insufficiency preop.

Of note, this patient is on glargine 25 units daily and aspart 4 units with each meal... Their diabetes medication choices are fairly similar to ours (long acting GLP-1 agonists are available as well)

The above patient underwent preop ultrasound as we observed. Of interest, we walked with the patient down 2 flights of stairs to reach the ultrasound room. The Centre has no dedicated transport staff (they have 2 assistants but they are busy performing blood draws, etc). After her formal US, Cord also performed an ultrasound for teaching purposes. She had bilateral ~1cm nodules, and a smaller cystic nodule on right. She had no suspicious LNs in lateral neck. Plan is for surgery tomorrow.

- 30 yo woman with severe HTN and hyperaldosteronism by biochemical testing. There was difficulty localizing (bilateral adrenal nodules) but AVS showed localization to the left. She had a chyle leak after surgery but this resolved.

Then she developed new abd pain and n/v, gastroscopy showed multiple peptic ulcers. Also found to have hepC and transaminitis. They are currently managing these conditions.

- 18yo woman s/p thyroidectomy with central neck for PTC, s/p 50 mCu RAI (definitely considered a "small dose").

Surgeon (outside facility) saw LNs in lateral neck during operation but didn't remove them. After surgery, TG was 100mg/dl during withdrawal. 6 months after RAI, TG was 67, WBS showed bilateral lateral signal, none in central. US completed at 1 year showed suspicious LN in left lateral comp. An FNA showed PTC, high TG in washout. Original doctors were considering repeat RAI tx but Centre recommended surgery and she underwent bilateral lateral neck surgery and central revision:- 6 metastatic LNs were found in left lateral, none on right. Recent repeat TG was 11 (withdrawal), 0.1 with tsh suppression, TG ab negative. Recent US noted small nodes under clavicle (but hard to FNA). Mother wants more intervention but Dimitry prefers to monitor; asks Cord for his opinion. Cord agreed. She has relatively low TG so likely very little cancer (maybe one LN ). He recommends avoid more RAI for now, monitor for growth with US and maybe WBS in 1yr. Thyroid suppression is most important. Would only pursue RAI only if pulmonary disease noted.

- 40 yo woman with hyperthyroidism found to have a 3cm left lobe nodule. The FNA showed ?follicular neoplasm but

Radio-iodine scan showed hyperactive (graves) over entire gland including an active nodule. She underwent RAI tx (usually 15-20 mCi for graves). Now she is hypothyroid and noted that nodule is growing. Repeat FNA showed PTC. She underwent thyroidectomy with central comp dissection, path showed PTC.

Next 2 cases were presented to us by Dr. Belaya (endocrinologist with expertise in bone disorders and parathyroid).

- 58 yo woman with primary hyperparathyroidism diagnosed at age 54 years. She underwent 2 surgeries for parathyroid nodule excision (each after scintigraphy): First thymus removed via sternotomy (for intra-thymus parathyroid gland) and, second, thyroid left lobectomy (via neck approach) for intrathyroidal parathyroid gland. Surgeries resulted in hypothyroidism but she remains hypercalcemic ( iCa 1.43 and iPTH elevated) despite cinacalcet.

Also she has been found now to have a very high gastrin (x5), serotonin (x1.5), and chromogranin A (x3) (not on PPI, no ulcers). Very likely she has MEN1. She has developed Osteoporosis (T-4.0 at radius and spine) and plan is for prolia tx. 

No sx kidney stones (but h/o them in past), Normal kidney function. Cord discussed if she should undergo 3rd operation, but clearly this is a difficult case. He recommended treatment of hyperparathyroidism first: likely best to get Sestamibi w SpectCT and ultrasound. CT angio may also help localize these very vascular parathyroid rumors. Then maybe selective venous cath to localize PTH secretion (needs repeat sternotomy?).  Probably she needs a redo bilateral neck exploration (maybe sternotomy) but better to do as much as possible in one surgery. Embolization (with angio ) can be considered but risk of stroke is1-2%. After this, she needs further neuroendocrine tumor workup.

- 2nd case: 36 yo woman with prolactinoma and hyperparathyroidism c/b kidney stones. She underwent surgery and had 6 parathyroids removed, no sternotomy. 2 glands left on imaging (bilateral), but one is 2.5 cm. No mutation of menin gene identified. She wants to have 3rd child. Cord recommended a 2nd operation. (take largest or both and autotransplant one into the arm (recurrence in arm would be preferable). 

We then discussed attitudes toward tolerance (Russia) vs absolute avoidance (US) of  surgical hypoparathyriodism in our countries. Also discussed development of PTH replacement (Natpara) which Dr. Belaya hopes will be a reasonable option soon.

After these cases, I presented a "Journal Club" to the residents of the Endocrinology Research Centre. This was a new experience for them as they do not routinely read and evaluate the medical literature in this way. Most of them are training for clinical medicine only and it is not considered a part of their training to learn to critically evaluate the medical literature. However, some of them, like Daria, are chosen to pursue research (often a PhD dissertation) and in this case they are given classes on statistics and journal reading/writing. Daria informs us that it is difficult to read in the Russian literature because most of it is not of very high quality and cannot be trusted. She is able to read and write very well in english (so can read english language medical publications) but this is not the norm. Daria had me explain at the start of my presentation and emphasize the importance of evaluating an article for limitations and potential bias (she felt this would be an important concept for the residents to recognize).

(I used Google-translate to try to convert some of my slides to the Russian Cyrillic script, but Daria had to help me correct some very comical errors)

We then completed our day by watching a bilateral neck dissection. The patient was HepC positive so the surgeons wore disposable paper gowns over their cloth ones (otherwise they always wear reusable cloth).

Of note:

Smoking rates appear to be much higher in Moscow than Chicago (smoking is still allowed in restaurants and bars). However, it is forbidden in the Endocrine Research Centre and our hosts are non smokers.

Weekend excursion to St. Petersburg

On the advice of our hosts, we took a weekend excursion to St. Petersburg. We took a high-speed train (4 hour trip). 

(Photo next to a not-so-high-speed train.)

While in St. Petersburg, we hired an excellent english-speaking guide named Irina. She is a native of St. Petersburg, has studied Russian history, and is incredibly knowledgeable of the history and culture of her city. Her tour allowed us to the vast majority of the numerous and incredible churches and palaces during our very short time.  I would highly recommend her services to anyone who is planning to visit. The following is her website (on Facebook):
https://m.facebook.com/Musetours.SPb?_rdr

We visited the State Hermitage Museum which contains an abundance of historical works of art (Rembrandt, Matisse, Picasso, DaVinci, just to name a few) housed in an incredible palace.
http://www.hermitagemuseum.org/html_En/index.html

 (Cord standing next to a painting of a man with a goiter)

We also visited a number of churches including Church of Our Savior on Spilled Blood and St. Isaac's Cathedral. Both had incredibly intricate frescos and paintings covering the walls and ceilings.
http://www.saint-petersburg.com/cathedrals/st-isaacs-cathedral.asp
http://www.saint-petersburg.com/virtual-tour/church-of-savior/

We then explored a number of palaces, including the Peterhof (created by Peter the Great) and Catherine Palace (named for Catherine I). The latter includes the famous "amber room" which is literally coated with frescoes made of amber. It is incredible (but unfortunately, pictures are not allowed, so I found a picture on the internet).
http://www.saint-petersburg.com/peterhof/index.asp
http://www.saint-petersburg.com/pushkin/catherine-palace.asp

(Cord and I standing over a canal leading up to the Peterhof) 

(Long hallway in Catherine Palace)

(Amber room)

 I loved St. Petersburg... I can't wait to return in the summer season when the fountains are functioning and the gardens are green.

Day #4

Today we started with a tour of the Endocrinology Research Centre's post-operative ICU. There we reviewed the following cases:
- man with ectopic ACTH production from sources in lungs
- woman with Cushing's disease s/p surgery but with complications (ARDS and steroid-induced psychosis)

We then discussed the following surgical patients with Dimitry:
- Woman with primary hyperaldosteronism that was shown to lateralize to AVS (contralateral to adrenal nodule identified by CT!). She underwent surgery but this was complicated by chyle leak noted due to drain in the abdomen.
- 40 yo woman with asymptomatic incidentally noted 2cm neck mass. This was AUS on FNA initially but follicular neoplasm vs. follicular variant of PTC on repeat. She was also noted to be hypercalcemic with elevated PTH. Scinitgraphy demonstrated L parathyroid gland (nodule also on L). She had yet to undergo surgery, so Dimitry intended to remove the L lobe and try frozen section (understanding this has limitations). We discussed use of frozen section (used more frequently here) and intra-op PTH levels (they are unable to do these, turnaround for their lab is about 40 min but they check post-op and the following day).

We then briefly visited a transsphenoidal resection of pituitary surgery that was in progress. They perform many of these at Endocrinology Research Centre, often up to 9 per week. They have a large number of Cushing's disease cases. Their OR equipment for this was very similar to the US.

Afterward, we returned to Dimitry's office for a discussion of a few thyroid cancer cases and the possible uses of frozen section.

Then Dr. Sturgeon presented his talk entitled "The Diagnosis and Management of Papillary Thyroid Cancer in the United States" to a large audience at the Endocrinology Research Centre.

(Dr. Sturgeon demonstrates video of using ultrasound to visualize movement of vocal chords)

(Questions from faculty after the talk)

At the end of the day, we met Pavel Rumyantsev, MD, PhD, the Deputy Director at the Endocrinology Research Centre. He is also an expert on radiation-induced thyroid cancer and has treated and studied a large group of patients with exposures relating to Chernobyl. He also gave us his impressions regarding the developing cases that may be related to Fukushima.

He also gave us a tour of the new additions to the Endocrinology Research Centre that are currently under construction. We saw the new inpatient rooms which will hold 2-4 patient per room. We also saw the operating suites and the ICU.