Vol 47, No 2 (2019)

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On the 90th anniversary of Nikolay Romanovich Paleev


Almanac of Clinical Medicine. 2019;47(2):95-97
pages 95-97 views


Diet barriers in type 2 diabetic patients and their coping strategies

Starostina E.G.


Background: Factors hindering effective nutritional therapy (diet barriers, DB) in type 2 diabetes mellitus (DM2), their coping strategies and association with biomedical and psychosocial characteristics of the Russian patients have not been studied.

Aim: To identify the role and clinical correlates of DB and diet coping in various categories of patients with DM2.

Materials and methods: This cross-sectional cohort study included 297 consecutively recruited out- and in-patients with DM2 (mean age 61±10.1 years, diabetes duration 1 to 35 years). All patients had standard clinical and laboratory assessments and filled in questionnaires on DB, diet coping, level of knowledge on DM, state/trait anxiety scale, depression scale (modified Zung), Diabetes Treatment Satisfaction questionnaire (DTSQ), Audit of Diabetes-dependent Quality of Life questionnaire (Ru-ADDoQL). Mann-Whitney, chi-square and Fischer's exact test were used for group comparisons. Final analysis was based on multiple and logistic regression models.

Results: Mean (±SD) number of DB per patient was 8.4±4.9 and similar in insulin-treated and non-insulin-treated patients. The most prevalent were DB related to poor physical well-being (51% of the patients), additional financial burden (54%) and decreased food variety (41%). The highest weighted prevalence was identified for 6 DB, such as “difficulties to adhere to the diet in unexpected situations” (1.8 scores), “having to spend a lot for the diet” (1.4), “if I eat not regularly, I feel unwell”, “I cannot eat tasty foods and enjoy them” (1.3  each), “when I  eat more than I  am allowed, I feel unwell”, “I would like to eat what it is not allowed for me” (1.2 each), and “it is difficult to fully abstain from sweets” (1.1). Number of DB per patient increased significantly with age and decreased with higher educational level and social status. There were differences in types of DB between male and female patients, between those currently employed and non-employed, and between highly compliant and non-compliant to their diabetes regimen. There was an inverse correlation between DB numbers and total dietary adherence score, diabetes-dependent quality of life score, subjective assessment of personal health status and a direct correlation between DB number and trait anxiety. No impact of past participation in a diabetes education program or of the level of knowledge on diabetes on DB number was found. For most DB the patients demonstrated the socalled compliant coping (i.e., adherence to the diet recommendations), excluding the DB “I am not allowed to eat when I am hungry”, which was associated mostly with intermediate coping styles that might unfavorably influence one's health status. The compliant diet coping scores were in a weak negative correlation with DB number and with the patient's level of knowledge on diabetes. DTSQ score weakly but significantly correlated with the total score of compliant and intermediate diet coping.

Conclusion: Main DB in DM2 are related to physical discomfort, financial problems and limitations in food choices. Individual DB content depends on age, gender, educational level, social status and employment. Higher numbers of DB per patient is associated with decreased possibility of compliant diet coping style. Overloaded diet recommendations are associated with an increase in DB number that may lead to poorer patient compliance to diabetes treatment in general, as well as to poorer diabetes-dependent quality of life. Elderly patients, as well as those with lower educational level, unemployed, with uncontrolled diabetes, poor general compliance and higher levels of anxiety and depression have the highest DB numbers. Individual DB are to be considered during therapeutic patient education in DM2 and patient-tailored approach to therapy. 

Almanac of Clinical Medicine. 2019;47(2):98-111
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Associations between obesity and vitamin D availability depending on the rs2228570 polymorphism of the VDR gene and rs9939609 polymorphism of the FTO gene in the midland and the Extreme North of Russia

Pogozheva A.V., Sorokina E.Y., Sokolnikov A.A.


Background: It has been shown that vitamin  D availability depends on the body mass index (BMI). Genetic polymorphisms contribute to the development of vitamin  D deficiency.

Aim: To study the availability of vitamin D in the population of various regions of the Russian Federation, depending on the BMI values and the rs2228570 polymorphisms of the VDR gene and rs9939609 of the FTO gene.

Materials and methods: The rs2228570 polymorphisms of the VDR gene and rs9939609 of the FTO gene were identified in 311 subjects (136, from the midland of Russia, and 175 from the Far North). Serum 25-hydroxyvitamin  D [25(OH)D] levels were measured by an immunoenzyme assay in the autumn and winter seasons. Genotyping was performed with the allele-specific amplification and real-time detection of results using TaqMan probes complementary to the polymorphic DNA segments and the CFX96 Real Time System amplifier (Bio-Rad, USA). We studied associations of the rs9939609 polymorphism of the fat mass and obesity-associated (FTO) gene located at 16q12.2, as well as the rs2228570 polymorphism of the vitamin D receptor gene (VDR) located at 12q13.11.

Results: Frank vitamin D deficiency (serum 25 (OH) D level<20 ng/ml) was observed in 39.7% (54/136) of the sample from the midland, in 40% (14/35) of the migrants and in 30.7% (43/140) of the indigenous inhabitants of the Far North (Nenets). Obese residents of the midland Russia had significantly lower serum 25(OH)D levels, and the indigenous population of the Far North had significantly higher levels than those with BMI<30 (р<0.05). In the indigenous population of the Northern Region, there was a  significant association between vitamin  D deficiency and C allele of the rs2228570 polymorphism of the VDR gene (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.46–4.27, p=0.0006) and the AA genotype of the rs9939609 polymorphism of the FTO gene (OR 8.83, 95% CI 0.94–82.5, p=0.02).

Conclusion: The association between obesity and vitamin  D availability in the individuals with the rs2228570 polymorphism of the VDR gene and the rs9939609 polymorphism of the FTO gene depends on their ethnicity. 

Almanac of Clinical Medicine. 2019;47(2):112-119
pages 112-119 views

Ultrasonography and fine-needle aspiration biopsy in the diagnosis of a cystic type of thyroid papillary cancer

Britvin T.A., Bondarenko E.V., Bondarenko V.O., Demidova T.Y.


Background: Cystic type of thyroid papillary carcinoma is a  rare independent disease of this organ. Its prevalence among papillary carcinomas is from 2.5 to 6%.

Aim: To identify ultrasonographic features of the cystic form of papillary carcinoma for the differential diagnosis of solitary liquid neoplasms of the thyroid and to elaborate an optimal technique for its fine-needle aspiration biopsy.

Materials and methods: We retrospectively analyzed the data on the diagnosis and treatment of 29  patients with the cystic type of thyroid papillary carcinoma (26  women, 3  men, mean age 52  years). The instrumental diagnosis was based on a  comprehensive ultrasonography and fine-needle aspiration biopsy.

Results: We identified the following ultrasonographic characteristics of “potentially malignant” cystic nodules of the thyroid: the wall thickness of  2 to  3  mm with marginal tissue components of various size (from 10 mm to 3 cm in diameter) and microcalcinates; presence of focal blood supply by color Doppler mapping; homogeneity and low echogenicity of the liquid component. Conclusion: The right interpretation of the ultrasonographic results and adequately performed fine-needle aspiration biopsy help to verify the diagnosis of thyroid carcinoma and to avoid mistake in the treatment of this patient category. 

Almanac of Clinical Medicine. 2019;47(2):120-125
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Questionnaire-assessed risk of sleep apnea in inpatients with various endocrine disorders

Misnikova I.V., Kovaleva Y.A., Gubkina V.A., Klimina N.A.


Background: Sleep breathing disorders can be an additional risk factor for the development of cardiovascular disorders in patients with endocrine disorders.

Aim: To assess the sleep apnea risk in patients with various endocrine disorders undergoing inpatient treatment.

Materials and methods: The sleep apnea risk and the severity of daytime sleepiness were evaluated in 282 inpatients with endocrine disorders based on the following questionnaires: the Epworth Sleepiness Scale (ESS), the sleep apnea screening questionnaire (SAS), and the Berlin sleep apnea risk questionnaire (BQ). To identify the real prevalence of sleep respiratory disorders in endocrine patients we performed cardio-respiratory monitoring with Watch-PAT200 (“Itamar Medical”, Israel) device in 81 patients.

Results: A high sleep apnea risk according to the BQ was detected in 59.9% (160/267) of the patients, according to the SAS in 53.53% (144/269), excessive daytime sleepiness (≥ 11 points) was found in 21.66% (60/277) of the patients with the ESS. Among the patients undergoing cardiorespiratory monitoring, sleep apnea was detected in 84% (68/81), including severe apnea in 38.2% (26/68). The highest sleep apnea risk by BQ and SAS was observed in the patients with type 2 diabetes, acromegaly and hypercortisolism. Excessive daytime sleepiness by the ESS was most noticeable in those with hypercortisolism and thyrotoxicosis.

Conclusion: The high risk of sleep apnea in the inpatients with type 2 diabetes mellitus, acromegaly, hypercorticism, and hypothyroidism makes it necessary to include its active screening into the algorithm of their inpatient assessment to rule out any sleep breathing disorder.

Almanac of Clinical Medicine. 2019;47(2):126-137
pages 126-137 views

Restoration of clinical and instrumental parameters of the cardiovascular system in patients with diffuse toxic goiter after resolution of thyrotoxicosis

Alekseeva O.A., Shaposhnik I.I., Bogdanov D.V.


Rationale: Evaluation of the cardiovascular system in patients with common thyroid disorders could be of interest from the perspective to identify new risk factors for cardiovascular events. Whether cardiovascular abnormalities associated with thyrotoxicosis would be reversible after its treatment, needs elucidation.

Aim: To assess the degree of restoration and prerequisites for reversion of the signs and symptoms of cardiac injury in the long term after conservative and surgical cure of thyrotoxicosis in patients with diffuse toxic goiter (DTG).

Materials and methods: This was an open longitudinal retrospective study performed in the Regional Center for Endocrine Surgery, Chelyabinsk Municipal Clinical Hospital No.  1 in 124 patients with past history of DTG. By the time of examination, all patients were in a stable clinical and laboratory remission after the withdrawal thyrostatic agents or were in controlled post-operative hypothyroidism for 1.5 to 5  years after surgery for DTG. The mean age of the conservatively treated patients (n=62) was 39.9±1.31 years (19 to 55  years). The mean age of the patients that had been treated surgically (n=62; subtotal thyroid resection) was 41.1±1.4 years (21 to 56 years). We compared with patients' complaints, electrocardiographic and echocardiographic parameters by the time of examination with the corresponding data at the time of the primary referral.

Results: In the long term after the elimination of thyrotoxicosis, 56.5%  (35/62) of the patients who had underwent surgery, were complaining of dyspnea, 54.8%  (34/62) of palpitations, and 50%  (31/62) of cardialgias (p<0.01), whereas among the conservatively treated patients the corresponding complaints were present in 59.7%  (37/62), 64.5%  (40/62), and 56.5%  (35/62) (p<0.01). Ninety nine (99) percent of the patients, who had arterial hypertension before the treatment, remained hypertensive at the follow-up. In 30% of the surgically treated patients the severity of arterial hypertension was higher than initially. In the surgery group, there was a decrease in the left atrium diameter in 17 patients and in the end-diastolic diameter of the right ventricle in 24 patients; all these patients did not have hypertension at baseline. No restoration of the heart chamber diameters was seen after conservative treatment and after surgery in patients with arterial hypertension. ST segment and T wave abnormalities were not associated with any clinical symptoms both at baseline and in the long term. At the long term follow up all patients had normal thyroid-stimulating hormone (TSH) and thyroxine (T4) levels, with no associations between TSH and T4 levels and clinical and instrumental assessment results. All patients with past history of DTG continued to have tachycardia, arterial hypertension, diastolic dysfunction and increased left ventricular myocardial mass.

Conclusion: Cardiovascular abnormalities persisted for a  long time after the elimination of DTG. Arterial hypertension that had arisen against the background of DTG had a negative impact on the structural and functional state of the heart in this disease, irrespective of the treatment method used. In the patients with past history of DTG, we identified such predictors of heart failure as tachycardia, arterial hypertension, diastolic dysfunction, increased left ventricular myocardial mass. 

Almanac of Clinical Medicine. 2019;47(2):138-148
pages 138-148 views


Current approaches to gender dysforia management: an endocrinologist’s perspective

Volkova N.I., Davidenko I.Y., Degtyareva Y.S.


Understanding of people with impaired gender identity in society, academic and science world is constantly changing due to increased awareness, openness and availability of the information on transgender people and their life. It is known that the social and psychological state of transgenders depends at a  great extent on the quality of their medical care, including hormonal treatment. Unfortunately, until recently the awareness of this problem among many physicians (clinical psychologists, psychiatrists, endocrinologists, etc.) in the Russian Federation remained insufficient, and no unified standards of medical and psychological care for transgender people in Russia have been developed. As a  result, when referring to various specialists, people with impaired gender identity commonly do not receive adequate recommendations and proper comprehensive medical follow-up. An endocrinologist, who prescribes hormonal treatment and performs long-term (usually life-long) follow-up and monitoring of adverse events, is one of the key team members to provide medical care to transgender patients. The article presents current views on definitions, diagnostic criteria and principles of endocrine therapy for gender dysphoria and gender incongruence, as well as highlights medical risks, associated with hormonal treatment, and a monitoring plan for patients receiving corrective therapy.
Almanac of Clinical Medicine. 2019;47(2):166-174
pages 166-174 views


A case of late manifestation of primary adrenal insufficiency in the autoimmune polyglandular syndrome type 1

Troshina V.V., Grebennikova T.A., Belaya Z.E.


The article describes a clinical case of primary adrenal insufficiency which manifested at an atypically advanced age. Primary adrenal insufficiency combined with other clinical symptoms suggested the autoimmune polyendocrine syndrome type 1. Subsequently, the diagnosis was confirmed by the results of genetic testing. The particulars of the clinical case include the age of patient at manifestation of the disease (49  years). The lack of treatment resulted in dramatic clinical decompensation. This clinical case is intended to draw clinicians' attention to the necessity of detection of primary adrenal insufficiency and appropriate and timely treatment. Taking into account eventual diagnostic problems, it is necessary to raise awareness about this disease among practicing doctors of various specialties.
Almanac of Clinical Medicine. 2019;47(2):175-179
pages 175-179 views

Mutations in the HNF1A gene as a cause of MODY3: a clinical case

Demidova T.Y., Gritskevich E.Y., Balutina O.V.


Genetic dysfunction of the pancreatic β-cells and/ or factors participating in glucose metabolism can form the bases for monogenic types of diabetes mellitus. Diagnosis of MODY type of diabetes is difficult due to its rare identification in the real clinical practice and to the necessity of molecular genetic testing for the confirmation of specific mutations. Errors in the diagnosis of diabetes mellitus may be misleading for the choice of hypoglycemic treatment, which is the key problem in the management of these patients. In the clinical case described, the diagnosis of MODY3 related to the mutations in the HNF1A transcriptional factor was confirmed during pregnancy of the patient, i.e. more than 15 years had passed from manifestation of the disease in childhood, despite typical clinical symptoms and specific familial history. Optimization of the early diagnosis and management of this patient cohort can be facilitated by accumulation of theoretical knowledge and practical experience, as well as improvement of diagnostic capacities, including higher availability of molecular genetic analysis.
Almanac of Clinical Medicine. 2019;47(2):180-185
pages 180-185 views

Severe depression and rhabdomyolysis as “masks” of primary hypothyroidism: clinical cases

Kulagina T.I., Koriakova N.V., Rodionova O.A., Vezikova N.N., Kannoeva I.I.


Rationale: Primary hypothyroidism is one of the most common endocrine disorders. Difficulties in its diagnosis are related to the lack of specific and pathognomonic clinical symptoms of the disease. It is not infrequent that before the right diagnosis is made, patients with hypothyroidism go a  long way of examinations and consultations of various specialists; we have illustrated this by two clinical cases.

Clinical case No. 1 was a 69-year old woman with a  late diagnosis of severe primary hypothyroidism. Despite the presence of typical clinical signs of hypothyroidism, such as epidermal and edematous syndromes, encephalopathy, depression, and anemia, some clinical patterns (significant weight loss, ascites, low cholesterol, protein, electrolyte levels, and severe anemia) directed the diagnostic search towards oncology. It was the oncologist who was the first to suggest hypothyroidism that was later confirmed by high thyroid-stimulating hormone (TSH) levels.

Clinical case No. 2 was a case of hypothyroidism in a young man with a baseline history of kidney disease. Fatigue, myalgia, neurological abnormalities, cytolysis and hypercholesterolemia were the leading symptoms that progressed steadily and led to disability.

Conclusion: These clinical cases demonstrate the variety of clinical symptoms in manifest hypothyroidism and emphasize the significance of high awareness of this disorder among various medical specialties. It is of note that laboratory tests to diagnose primary hypothyroidism are very simple and available (high serum TSH level is enough for the diagnosis) and treatment with levothyroxine sodium is very effective. 

Almanac of Clinical Medicine. 2019;47(2):186-194
pages 186-194 views


Genetic predictors of insulin-producing pancreatic tumor

Yukina M.Y., Nuralieva N.F., Troshina E.A.


Insulinoma is the most common functioning tumor of the pancreas. Approximately 5% of its cases are associated with the multiple endocrine neoplasia syndrome type 1 (MEN1), caused by mutation in the MEN1 gene. MEN1 can be manifested by pituitary and parathyroid adenomas, pancreatic neuroendocrine tumors, tumors of the thyroid gland, adrenals, intestine, carcinoids of lungs and other organs. However, in 5–10% of the patients with clinical manifestation of this syndrome, MEN1 mutations cannot be identified. Moreover, the disease can be caused by various abnormalities (mutations, polymorphisms, etc.) in other genes. More than 30 genes, associated with insulin-producing pancreatic tumors, have been described in the literature. With a known germinal mutation, the prognosis and management of patients with insulinoma can be determined by the hereditary disease with which the tumor is associated. The article emphasizes the need to search for new genetic markers that predispose to the development of insulinoma. The necessity of extended genetic testing of patients with insulinomas is discussed, primarily of young patients with multifocal lesions, family history and associated disorders.
Almanac of Clinical Medicine. 2019;47(2):149-155
pages 149-155 views

Amiodarone-induced thyrotoxicosis type 2: predictors and treatment options

Ermolaeva A.S., Biakina O.A., Sytch J.P., Kopylov P.Y., Fadeev V.V.


Amiodarone-induced type 2 thyrotoxicosis remains a  significant problem of modern endocrinology and cardiology. The unique pharmacological character and multifaceted properties of amiodarone explain its high prescription frequency and the leading position among antiarrhythmic drugs. In its turn, cytotoxicity and supra-physiological iodine content in the drug increase the risk of drug-induced destructive thyroiditis. The development of thyrotoxicosis leads to recurrence of cardiac arrhythmias, increased left ventricular dysfunction and manifestations of chronic heart failure. Correct identification of the type of thyrotoxicosis determines the subsequent patient management strategy. Glucocorticoids have been recognized as the first-line treatment among the possible therapy options. Rapid correction of thyrotoxicosis is crucial, especially in elderly patients with severe heart disease. Of interest for practical medicine is the search for specific predictors (deep understanding of the pathogenetic mechanisms) and new possibilities of therapy for amiodarone-induced thyrotoxicosis type 2.
Almanac of Clinical Medicine. 2019;47(2):156-165
pages 156-165 views

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