No 32 (2014)



Bobrov A.E., Gegel N.V., Gurova O.Y., Romantsova T.I., Savel’eva L.V.


Background: Eating in obesity represents behavioral systems more powerful than conscious self-control. Aim: To study the obese patients’ behavior with the help of clinical-psychopathological and personal style criteria. Materials and methods: A total of 149 patients (aged 19-69 years), who sought medical help due to obesity or overweight were examined. Their physical condition was satisfactory and concomitant somatic diseases were compensated. Patients’ behavior was assessed by diagnostic criteria ICD-10 as well as with a Minnesota Multiphasic Personality Inventory (psychological testing). Results: It was established that psychical impairments existed in 98 (65.8%) patients. The anxiety disorders (in 65 patients, 43.6%) and affective ones (in 41 patients, 31.5%) were noted most frequently. Factor analysis of the psychological test data revealed 5 main styles of behavior in patients with overweight and obesity: borderline, hyperthymic, dysthymic, sensitive, and undifferentiated. Neither these behavioral styles nor the frequency of disorders corresponded to the degree of obesity. Conclusion: Disturbances of eating self-regulation in obesity are associated with different behavioral styles, which are not specific for mental disorders only. These behavioral styles are described in the study as well as corresponding psychological mechanisms of overeating.

Almanac of Clinical Medicine. 2014;(32):3-7
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Krivikhin V.T., Krivikhin D.V., Chernobay A.V., Lobakov A.I., Bakunov M.Y.


Background: The development of purulent-necrotic complications in patients with diabetic foot syndrome (DFS) is a cause of high amputations, early disablement, resulting in development of metabolic syndrome and progression of cardiovascular complications. Today, the methods of treatment of purulent-necrotic lesions in DFS are aimed at preserving the supporting function of an extremity. The presence of extensive purulent-necrotic leg wounds is a risk factor of urgent indications for amputation. Aim: To develop an algorithm of treatment of extensive purulent-necrotic leg wounds in patients with neuropathic form of DFS. Materials and methods:  At the Regional Center “Diabetic foot” on the basis of Vidnoe regional clinical hospital, during a period of 2009 to 2013, the treatment results were analyzed in 62 patients with neuropathic form of DFS and extensive purulent-necrotic leg wounds. All patients underwent an active surgical intervention together with the complex conservative therapy. Treatment consisted of several stages: wound cleansing up to the appearance of granulation tissue – autodermoplasty – stimulation of epithelization. The efficiency of treatment was assessed depending on the time needed for wound cleansing, granulation, epithelization, and on the number of high amputations. Results: All patients underwent primary radical surgery to cross the pathways of purulent infection spreading in the proximal direction followed by an open management of the wound. Subsequently, the staged necrectomies were carried out along with a conservative therapy aimed at wound cleansing. The average time of wound cleansing was 10.6±1.2 days. Formation of granulation tissue took 8.4±0.8 days after the first surgery. When the purified granulation tissue was obtained, the patients underwent autodermoplasty with a free split tissue flap to stimulate epithelization. The process of epithelization started on the 10.2±0.6 day. At the admission to the hospital, on the 4-10th day after the first surgical intervention, an index of leukocyte infiltration was measured. Normalization of this index during treatment is indicative of the successful wound cleansing and satisfactory course of the wound healing. A single (1.6%) high amputation was performed in this group of patients within the period of 2009 to 2013. Conclusion: Active surgical tactics involving excision of the primary purulent focus, intersection of purulent pathways (tendons, fascia), open management of the wound, and subsequent staged necrectomies combined with a conservative therapy – all contribute to the maximum wound cleansing, reduction of intoxication level, and activation of reparative process. Timely autodermoplasty accelerates the process of epithelization and wound healing.

Almanac of Clinical Medicine. 2014;(32):8-11
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Misnikova I.V., Dreval’ A.V., Kovaleva Y.A., Gubkina V.A.


Background: It is extremely important to have information about the main epidemiological indicators characterizing the situation on diabetes mellitus (DM) in Moscow Region. Aim: To assess the dynamics of the main epidemiological indicators of type 1 DM (T1DM) and type 2 DM (T2DM) for the 10-year period (2004-2013). Materials and methods: The study was performed based on the analysis of data of the Moscow Region DM Register, which contained information about 202 909 patients with DM. The indicators are presented per 100 000 of the population. Results: The T1DM prevalence increased from 132.09 to 166.6 per 100 000 within a decade fixed, and that of DM2 – from  2121.9  to 3263.12. The T2DM incidence increased from 193.22 to 224.4. T1DM mortality decreased from 0.9 to 0.6 per 100 000, and in patients with DM2 – from 68.3 to 61.4. The average life expectancy in adult patients with T1DM increased by 1.3 years, in patients with T2DM – by 1.7 years. Conclusion: It was found that the registered prevalence of both T2DM (35%) and T1DM (by 20.5%) increased within the 10-year period. Increase of T2DM incidence was noted in individuals under 40 years of age, and the average peak of T1DM morbidity shifted from the age group of 10-14 years to the 7-9-year group. Cardiovascular diseases are still the prevailing cause of death in T2DM patients (60%). In T1DM patients, the main cause of death was chronic renal failure if onset of the disease occurred in patients under 25, and macrovascular complications – if the first disease manifestation was noted in patients above 25.

Almanac of Clinical Medicine. 2014;(32):12-16
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Starostina E.G., Moshnyaga E.N., Volodina M.N., Malakhova T.S.


Background: Non-psychotic mental disorders including non-severe depressive, anxiety and organic disorders can have an impact on the course and prognosis of the underlying disease in patients with diabetes mellitus (DM). Therefore, assessment of their epidemiologic aspects is extremely important. Aim:  Investigation of the types and prevalence of the major mental disorders among both type 1 DM (T1DM) and type 2 DM (T2DM) in-patients, determination of possible etiology of the organic involvement of the brain in T1DM patients as well as of the rate of diagnostics and management of mental disorders in DM patients in routine medical practice. Materials and methods: Part 1 was a cross-sectional study in 228 consecutive DM patients aged from 18 to 75 years, aimed at detection of current mental disorders. Part 2 was a cross-sectional study in 72 consecutive T1DM patients with in-depth assessment of signs of organic brain involvement. All patients underwent cognitive function tests. Mental disorders were diagnosed by a psychiatrist according to ICD-10 diagnostic criteria. Results: Mental disorders were  found  in 80.3% of patients, being significantly more prevalent in patients with T2DM (87.9%) than in T1DM patients (57.4%, р<0.0001). Anxiety disorders as a whole were diagnosed as frequently as depressive ones (39.5% and 40.0%, respectively), being the most prevalent both in T1DM (35%) and T2DM (60%). Within the class of anxiety disorders, diabetes-specific phobias of injections and hypoglycemia were noted 8-fold more often (р<0.01) in T1DM than in T2DM patients. Generalized (22.4 versus 9.3%) and organic (18 versus 0%) anxiety disorders as well as unipolar depressive episodes and dysthymia (40.2 versus 25.9%, р<0.05) occurred considerably more often in T2DM than in T1DM patients. In total, signs of organic brain involvement were found in 37% of T1DM patients. Possible etiologic factors of organic brain disorders were as follows: craniocerebral injury including concussion of the brain, severe hypoglycemia, and diabetic ketoacidosis – in 40.7% of patients each; alcohol abuse – 30.7%; arterial hypertension – 22.2%; ante- and intranatal factors – 11.1%; neuroinfections/intoxications and occupational neurotropic factors – in 7.4% each; electric trauma, general malnutrition, stroke, and brain tumor – in 3.7% each. None of the listed potential causes could be found only in one patient with organic brain involvement (3.7%). In T1DM patients, organic brain involvement was nonspecific, and there was no evidence of its association with the level of glycated hemoglobin, acute and chronic vascular diabetic complications. Conclusion: The present investigation revealed a high prevalence of non-severe mental disorders with predominance of generalized anxiety disorders and unipolar protracted depressions in T2DM in-patients and specific phobias in T1DM patients. Organic brain involvement (encephalopathy) occurs in every third young T1DM patient; however, in the majority of cases, its potential etiology is linked with factors unrelated to DM or non-specific for DM (for example, hypoglycemia). In routine medical practice, diagnostics and treatment of mental disorders in DM patients are close to non-existent. 

Almanac of Clinical Medicine. 2014;(32):17-23
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Nechaeva O.A., Dreval’ A.V., Mamedova T.R., Britvin T.A., Shestakova T.P., Komerdus I.V.


Background: Taking into account that many psychophysiological parameters directly depend on the severity and duration of pathological process and on the efficiency of treatment, investigations asessing remote results, health-related quality of life, and psychoemotional status of patients with a diffuse toxic goiter for a long time after radical treatment – are extremely urgent. Aim: To analyse the efficiency and safety of the radical methods of diffuse toxic goiter treatment, to compare the indices of the health-related quality of life, anxiety and depression levels depending on the kind of chosen methods of radical treatment. Materials and methods: A total of 71 patients with a diffuse toxic goiter were recruited into the study (37 patients who agreed radioiodine therapy, and 34 patients who underwent subtotal resection of the thyroid gland). Clinical examination, laboratory and instrumental analyses were carried out prior to and in 12 months after treatment. The questionnaire MOS SF-36 was used to estimate the health-related quality of life, Spillberg’s Anxiety Scale – to assess the levels of enxiety, and Beck Depression Inventory –   to assess the level of depression. Results: In the group of radioiodine therapy, the median of therapeutic activity was 12.7 [8.5; 15.2] mKi. After radioiodine therapy, the aim of treatment (hypothyroidism) was achieved in 95% of cases, and in 100% of cases – after subtotal thyroid resection. The MOS SF-36 questionnaire showed that the indices of the health-related quality of life in patients became significantly higher, and the anxiety level in 12 months after treatment – significantly lower than those before treatment (р<0.05). Conclusion: The obtained results demonstrated the effectiveness of both methods used for treatment of Grave’s disease. The type of radical treatment made no difference. Compared with the initial thyrotoxicosis, compensated hypothyroidism in both cases was followed by a significantly higher quality of life and lower levels of anxiety and depression. It was also shown that people who received radical treatment, despite compensated hypothyroidism, overall, had lower quality of life, than those who did not have thyroid disease.

Almanac of Clinical Medicine. 2014;(32):24-30
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Dreval’ A.V., Pokramovich Y.G., Trigolosova I.V., Vinogradova A.V., Ilovayskaya I.A.


Background: Somatostatin analogues therapy is an important part of the acromegalic patients’ treatment. Aim: Assessment of treatment efficiency for patients with acromegaly using different doses of somatostatin analogues. Materials and methods: The data of 128 acromegaly patients registered in Moscow Region were analyzed, 79 (61.7%) of them were treated with somatostatin analogues. The treatment was started with a dose of 20 mg. If the target levels of growth hormone (GH) and type 1 insulin-like growth factor (IGF-1) were not achieved within 6-12 months, the dose was increased to 30 mg, and then to 40 mg. If GH and IGF-1 levels fell under the target values, the dose was decreased to 10 mg. The rate of achievement of optimal GH and IGF-1 levels was analyzed depending on the somatostatin analogue doses used. Results: The percentage of the acromegalic patients who were under the first and the second lines of drug therapy, was almost similar:  55.7 and 44.3%, respectively. Sandostatin LAR in dose of 10 mg was given to 4 (5.1%) of 79 patients, 20 mg – to 33 (41.8%), 30 mg – to 11 (13.9%), and 40 mg – to 31 (39.2%) patients. The target levels of GH and IGF-1 were achieved in 57.6, 54.5, and 32.2% of patients, who received preparation in doses 20, 30, and 40 mg, respectively. Achievement of, at least, one planned criterium (GH or IGF-1) was additionally noted in 10 of 33 (30.3%), 4 of 11 (36.2%), and 9 of 31 (29%) patients within these study groups. The rate of side effects didn’t increase with the raising of оctreotide dose. Conclusion: Application of long-acting release octreotide (Sandostatin-LAR) in doses of 30 and 40 mg is safe and allows to increase percentage of acromegalic patients who achieve a biochemical control over acromegaly.

Almanac of Clinical Medicine. 2014;(32):31-35
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Tsoy U.A., Korostovtseva L.S., Sviryaev Y.V., Semenov A.P., Vaulina D.A., Kravchenko S.O., Konradi A.O., Grineva E.N.


Background: Obstructive sleep disordered breathing or obstructive sleep apnea (OSA) is the most common respiratory impairment in acromegaly. OSA is bound up with heightened cardiovascular mortality. Aim: Тo study frequency, features, and structure of sleep disordered breathing in patients with newly diagnosed acromegaly and to elucidate the factors influencing their development. Materials and methods: 38 patients (10 men, 28 women, median age 53 (28-76) years, median body mass index (BMI) 29 (19.9-44.3) kg/m²) with newly diagnosed acromegaly were recruited into the study. All subjects underwent full polysomnography (Embla N7000, Natus, USA) and Remlogica software (USA). Results: Sleep disordered breathing was found in 28 (73.7%) patients. OSA was revealed in all cases, in 11 (39.3%) subjects it was mixed. In 10 (35.7%) patients OSA was mild, in 8 (28.6%) moderate, and in 10 (35.7%) severe. BMI (р<0.01), disease duration (р=0.003), and insulin-like growth factor-1 (IGF-1) level (р=0.04) were different in patients without OSA and patients with moderate-to-severe OSA. No difference was found in sex (р=0.4), age (р=0.064), and growth hormone level (р=0.6). Frequency of arterial hypertension, diabetes mellitus, and other glucose metabolism impairments was the same in subjects without OSA and with severe-to-moderate OSA. Conclusion: All patients with newly diagnosed acromegaly should undergo polysomnography. BMI, disease duration, and IGF-1 level are significant risk factors for OSA development. Correlation OSA with arterial hypertension and glucose metabolism impairments needs to be further investigated.

Almanac of Clinical Medicine. 2014;(32):36-42
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Marchenkova L.A., Prokhorova E.A., Dreval’ A.V., Polyakova E.Y., Petukhova N.Y., Vishnyakova M.V.


Aim: To estimate the influence of postmenopausal osteoporosis (PMO) and subclinical vertebral fractures (SVF) on the quality of life of women in postmenopause. Materials and methods: This study was carried out in 508 postmenopausal women aged 37-88 years, a median – 63 years [57; 70], who were divided into 3 groups depending on bone mineral density (BMD) level: PMO (n=362), osteopenia (n=78) and normal BMD (n=68). The quality of life was assessed by using the questionnaire of the European Osteoporosis Foundation – QUALEFFO-41 with 41 questions in the following seven domains: А – а pain, B – activities of daily living, C – jobs around the house, D – mobility, E – leisure, social activities, F – general health perception, G – mental functions, and total QUALEFFO score as well, where the highest score corresponded to the lowest quality of life. Results: The quality of life in patients with PMO for domain С was worse (p<0.05) as compared to that in groups “normal BMD” and “normal BMD + osteopenia”; for domain G – as compared to that of groups “osteopenia” and “normal BMD + osteopenia”; and for domain D and total QUALEFFO score – as compared to that in the group “normal BMD + osteopenia”. A positive correlation (p<0.05) was found between the total number of SVF and the number of SVF in lumbar spine, and scores for domains А-E and total score of QUALEFFO-41 questionnaire. A statistically significant decrease of the quality of life (p<0.05) was noted in PMO patients who had at least one SVF as compared to women without SVF for domains А-E and a total QUALEFFO score. Conclusion: PMO and SVF are associated with a decrease of the quality of life in postmenopausal women. Due to a high diagnostic value of QUALEFFO-41 questionnaire, its validation is necessary in Russian Federation.

Almanac of Clinical Medicine. 2014;(32):43-49
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Nikitinskaya O.A., Toroptsova N.V.


Background: Application of the Russian FRAX® tool for solving a problem of antiosteoporotic therapy administration is urgent for our country. However today, there is no information confirming its high prognostiс value for wide clinical practice. Aim: Assessment of sensitivity and specificity of the Russian FRAX® tool in therapy of women aged 50 years and above. Materials and methods: Our pilot investigation involved 117 women of 50 to 79 years (mean age 64±7.1 years), examined in Nasonova Research Institute of Rheumatology in 2003. All patients filled in a FRAX® questionnaire to reveal absolute risk of fractures within a 10-year period of time. The risk of the most common osteoporotic fractures was assessed according to the threshold of the therapeutic treatment urgency brought forward by the Russian Association on Osteoporosis in 2012, with and without the Bone Mineral Density (BMD) taken into account. In 2003, the telephone questioning of patients was carried out to register possible fractures within the past decade. Results: During the 10-year period studied, the fractures of a minimal traumatic level were noted in 67 (57%) women (fractures of fingers, toes, and skull were ignored). The mean FRAX® score for the most common osteoporotic fractures, regardless of BMD, was higher in women with subsequent fractures than in those without them (p=0.005). The difference between mean FRAX® scores for hip fractures in these groups of women was statistically insignificant. When BMD measures of the hip neck were included into the FRAX® tool, the data obtained were similar. FRAX® tool scores, regardless of BMD, above the threshold of therapeutic treatment urgency were revealed in 41 (35%) women. The differences in prevalence of the high FRAX® scores for both most common osteoporotic fractures and hip fractures alone were absent among both the women with subsequent fractures and those without them. Sensitivity of the Russian FRAX® tool, regardless of BMD values, for the most common osteoporotic fractures formed 42%, and specificity – 74%. Given BMD values of the hip neck, sensitivity of the FRAX® tool for the most common osteoporotic fractures diminished to 28% but specificity grew to 84%. Presence of fractures in patients’ history increased for them the risk of the subsequent fractures 2.7 fold (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.21-6.28, p=0,02) independently of the FRAX® score. When FRAX® score is higher than the threshold of the therapeutic treatment urgency, the risk of subsequent fractures in women who had them in the past increased 10.8 fold (OR = 10.78; 95% CI = 2.48-55.97; p=0.0001). Smoking, early menopause, hip fracture in parents associated with a high FRAX® score of a patient didn’t additionally increase the risk of subsequent fractures. Conclusion. The preliminary data obtained are indicative of the low sensitivity and specificity of the present version of therapeutic treatment urgency threshold of the Russian FRAX®  tool for the most common osteoporotic fractures. Further epidemiological investigations are needed for correction of this version.

Almanac of Clinical Medicine. 2014;(32):50-55
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Pamputis S.N., Alexandrov Y.K., Lopatnikova E.N.


Background: Pathophysiologic interaction between vitamin D and hyperparathyroidism (HPT) is under investigation, never being systematically studied and remaining incompletely understood till now. Aim: To define the effect of vitamin D insufficiency/deficiency on the clinical course of HPT as well as on the pre- and postoperative periods in patients with primary HPT. Materials and methods: Definition of vitamin D level, a test with alfacalcidol, and a fine-needle aspiration punction biopsy together with determination of parathyroid hormone (PTH) level in the needle lavage were included into the laboratory and instrumental examination of 374 patients with increased PTH level. Results: Definition of the vitamin D level gives a chance to differentiate between a mild form of primary HPT and secondary HPT in patients with vitamin D insufficiency/deficiency. Information on the vitamin D insufficiency/deficiency in primary HPT patients at the pre-surgical stage allows to forecast significant decrease in the ionized calcium level in the postoperative period. Conclusion: Definition of vitamin D level is a necessary component of laboratory diagnostics in all patients with a raised PTH level. Every patient with normocalcemia, normocalciuria and increased PTH level should undergo verification of HPT using the test with alfacalcidol. Normocalcemic variant of primary HPT is due to the vitamin D insufficiency/deficiency. The vitamin D insufficiency/deficiency, defined in patients at the pre-surgical stage, gives an opportunity to suggest a significant decrease in the serum ionized calcium level after parathyroidectomy and to start in time an oral treatment of hypocalcemia, providing differentiation between primary HPT recurrence and vitamin D insufficiency/deficiency in postoperative period, thereby avoiding additional observation and unjustified repeated operations.

Almanac of Clinical Medicine. 2014;(32):56-60
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Turova E.L., Kozhemyakina E.V., Pukhtinskaya P.S., Lesnyak O.M.


Background: Multiple sclerosis is a chronic autoimmune progressing disease of the nervous system characterized by increased fracture risk due to a series of causes including the low bone mineral density (BMD). According to the literature data, the multiple sclerosis patients of a young age can already have BMD under the age norm. Factors associated with low BMD in such patients need to be investigated. Aim: Assessment of the prevalence of the low BMD level in young multiple sclerosis patients and revealing factors enabling its decrease. Materials and methods: Age was a patient criterium for including into the study: 18 to 50 years for men and 18 to menopause – for women. Under examination there were 163 patients with multiple sclerosis, 111 women (68.1%) and 52 men (31.9%) with mean age of 36.1±7.6 years. Relapsing-remitting multiple sclerosis was diagnosed in 121 (74.2%) patients, secondary progressive multiple sclerosis – in 37 (22.7%), and primary progressive multiple sclerosis – in 5 (3.1%). Score median according to the Expanded Disability Status Scale (EDSS) was 3.5 (25% and 75% quartiles – [2,0; 5,5]). The median of the disease duration was 8.5 [5.0; 14.0] years. BMD measuring was carried out using dual-energetic roentgen absorptiometry. Investigation was performed on two skeleton points: on the lumbar spine and proximal hip. Results: Decrease of BMD to under the age norm according to Z-criterion was revealed in 30 (18.4%) patients. The results obtained has shown that the body mass index (odds ratio (OR) 0.8; 95% confidence interval (CI) 0.7-0.9, p=0.001), disease duration (OR 1,1; 95% CI 1.0-1.2, p=0.023), the number of gluco-corticosteroid therapy courses (ОR 1.3; 95% CI 1.0-1.6, р=0.03), and smoking (ОR 2.7; 95% CI 1.0-7.2, р=0.04) are independent factors causing low BMD values in the patient population of multiple sclerosis studied. Conclusion. Every forth multiple sclerosis patient has decreased BMD in young age. Disease duration, low body mass index, gluco-corticosteroid taking, and smoking are significant factors influencing BMD in the young population of multiple sclerosis studied.

Almanac of Clinical Medicine. 2014;(32):61-65
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Khodyrev V.N., Lesnyak O.M., Martinchik A.N., Maksimov D.M.


Aim:  To assess the providing an organism with vitamins (А, В2, С, Е), β-carotene, and calcium in osteoporosis patients by measuring their intake and plasma concentrations. Materials and methods: 108 pairs “osteoporosis patient – healthy volunteer” aged 64.29±9.73 years were formed using a “case-control” method. Real intake of vitamins and calcium was studied defining the frequency of food taking for a month using questionnaire method. Daily intake of vitamins А, В2, С, Е, β-carotene, and calcium was calculated based on the analysis of the frequency of food taking. Among the basic group, using randomized method, 60% of osteoporosis patients were selected who underwent definition of plasma levels of vitamins А, В2, С, and Е. The same study was performed in 60 control volunteers. Results: Correlation of the intake of vitamins A, C, and β-carotene with their plasma levels wasn’t noted. It may reveal an increased need in these nutrients in osteoporosis. According to the calcium intake, every osteoporosis patient can be attributed to a population category with deep insufficiency of calcium intake (less than 500 mg a day). Conclusion: The data obtained need further investigation and, first of all, in clinical and biochemical fields (enzymatic non-provision for calcium uptake, clinical manifestations of insufficient provision with nutrients). Solution of these problems would enable regulation of food intake concerning calcium uptake in osteoporosis.

Almanac of Clinical Medicine. 2014;(32):66-72
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Evstigneeva L.P.


Physical activity and exercises play an important role in the prevention and treatment of osteoporosis. Clinical studies demonstrated the effectiveness of exercises manifesting themselves in small increase of bone mineral density and reduction of the risk of falls. In patients with vertebral fractures, the exercises improve the quality of life, posture, and mobility. The exercise effect depends on the type of exercises and on the study population. For patients with osteoporosis, it is reasonable to combine aerobic exercises with resistance training and exercises aimed at training of balance. In order to avoid adverse events, exercises should be started gradually. Patients with vertebral fractures may additionally undergo orthoses and physiotherapy.

Almanac of Clinical Medicine. 2014;(32):73-79
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Makeeva E.I., Oskolа E.V., Shubinа A.T., Karpov Y.A.


Diabetes mellitus is an important problem for every country in the world. The type 2 diabetes mellitus (T2DM) enables development of atherosclerosis and increases the risk of cardiovascular disease. Blood glucose control has been shown to be the most relevant factor for the prevention of the cardiovascular complications in T2DM patients. The cardiovascular protective effect of oral antidiabetic drugs is still under investigation. In this respect, we concern to be prospective the innovative oral hypoglycaemic agents such as the dipeptidyl peptidase-4 inhibitors.

Almanac of Clinical Medicine. 2014;(32):80-88
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Trigolosova I.V., Vinogradova A.V., Kruglyakova M.V.


There are many endocrine diseases accompanied by development of secondary diabetes mellitus (sDM). The features of the development and course of sDM in acromegaly, Cushing’s syndrome, and growth hormone (GH) deficiency are of particular interest as the prevalence of sDM associated with these pathologies is higher than that in the population. The main risk factors for sDM in acromegaly are age, female gender, arterial hypertension, family history of type 2 DM (T2DM), acromegaly activity, and duration and certain treatment methods of acromegaly. The differences of the sDM pathogenesis from pathogenesis of T2DM in the population are due to the opposite effect of GH and insulin-like growth factor 1 on glucose metabolism as well as to effect of acromegaly treatment on the mechanisms of diabetes development. The prevalence of diabetes in patients with GH deficiency, especially against the background of GH replacement therapy, is slightly higher than that in population. However, some studies have shown that GH replacement therapy may lead to normalization of the impaired glucose metabolism. High prevalence of metabolic syndrome (43%) and visceral obesity in the GH deficiency are the causes of the development of lipotoxicity (free fatty acids excess) and insulin resistance.In Cushing’s syndrome, the prevalence of early carbohydrate metabolism disturbances may reach 70%. In Cushing’s disease, chronic glucocorticoid excess determines insulin resistance and reduces insulin secretion, which results in hyperglycaemia. Currently, the recommendations for the treatment of sDM in acromegaly, hypercortisolism, and GH deficiency are the same as for the treatment of T2DM. However, as the pathogenesis is different in sDM and T2DM, the new algorithms for the diagnosis, prevention and treatment need to be developed. Prevention and timely treatment based on pathological principals will slow down the development of micro- and macrovascular complications leading to early disability and death of patients with neuroendocrine diseases.

Almanac of Clinical Medicine. 2014;(32):89-96
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Dreval’ A.V., Ilovayskaya I.A., Pokramovich Y.G., Stashuk G.A., Tishenina R.S.


Normalization of the growth hormone and IGF-1 levels during somatostatin analogs treatment usually is a predictor of somatotropinoma volume reduction. However, dissociation of biochemical and tumor-supressive effects of somatostatin analogs was also noted. We represent the female patient who showed reduction of the GH levels from 34.3 to 3.1 ng/ml and IGF-1 levels from 796 to 415 ng/ml (the gender and age upper normal limit 262 ng/ml) within 36 months treatment with maximum doses of somatostatin analogs (octreotide LAR 40 mg). Despite the lack of biochemical control of acromegaly, progressive decrease of tumor volume by 44 – 64 – 73% from initial volume (during 12 – 24 – 36 months of treatment) was noted. This case shows that it is possible to expect considerable reduction of somatotropinoma volume during treatment with somatostatin analogs even without achievement of complete control over GH and IGF-1 secretion.

Almanac of Clinical Medicine. 2014;(32):97-100
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Kalinin A.P., Kotova I.V., Britvin T.A., Alaev D.S., Beloshitskiy M.E.


The paper presents the peculiarities of history, clinic, presurgical preparation, surgical intervention, and postoperative period in patients with hypercalcemic crisis caused by primary hyperparathyroidism (PHPT). During 2000-2013, 5 of 214 patients with PHPT who developed hypercalcemic crisis were operated on. In 3 of them, histological analysis verified parathyroid adenoma, in 1 – parathyroid hyperplasia, and in 1 – parathyroid carcinoma. In 4 of 5 patients, PHPT was first revealed against the background of hypercalcemic crisis. In one female patient, PHPT was found “against the background” of 25-26-week pregnancy. Due to abdominal symptoms (abdominal pain, vomiting) characteristic of the hypercalcemic crisis, she underwent abdominal cavity revision in the Central Municipal Hospital. PHPT was diagnosed later, in the MONIKI Department of Abdominal Surgery. In the other female patient who was observed at the place of her residence for arthritis, the level of parathyroid hormone (PTH) before surgery reached 6490 pg/ml, and calcium – 3.75 mol/L. In the postoperative period, she developed not only acute renal but also adrenal failure. In one patient with known PHPT and not very high calcium and PTH levels, hypercalcemic crisis developed against the background of abdominal surgery. This female patient was operated on in two days after the first operation because she was in coma due to developed hypercalcemic crisis. Two more female patients were admitted to the clinic of endocrine surgery in severe condition. In one of them, PHPT was mistaken for rheumatoid arthritis or myeloid disease for several years, in the other, polyuria of unclear genesis was noted. In 4 of these 5 patients, in the nearest postoperative period, marked electrolytic disturbances developed (decreased levels of calcium, potassium, phosphorus, and magnesium) as well as an acute renal failure, polyorganic insufficiency, and syndrome of disseminated intravascular blood coagulation. In the nearest postoperative period, three patients died (on the 22nd, 32nd, and 34th day). In this connection, in patients with revealed PHPT, the surgical operations for the given disease as well as on the other organs should be performed simultaneously. The levels of creatinine, calcium, phosphorus, magnesium, and blood potassium should be under the control as well as an arterial pressure (every 2-3 hours), and blood coagulation (not less than during 10 days and then every week during 2-3 months at the place of residence).

Almanac of Clinical Medicine. 2014;(32):101-104
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Polyakova G.A., Kalinin A.P.


Background: Adrenal myelolipoma is a rare tumor, etiology and pathogenesis of which aren’t completely defined. Intensified investigation of the tumor structural components in concomitant adrenal lesions and associated diseases enables more comprehensive discovery of its histogenesis features and more adequate assessment of the cause of different correlations between adipose and hemopoietic components of the tumor. Aim: Specification of the structural features of different variants of adrenal myelomas based on the analysis of the outcome of this tumor morphologic study including possible influence of associated diseases. Materials and methods: A total of 16 observations of adrenal myelolipomas are presented in the study including 11 “pure” tumors, 2 mixed (adenomas/myelolipomas), and 3 concurrent ones (adenoma and myelolipoma). Results: Correlation between hemopoietic elements and adipose tissue varies in both “pure” myelolipoma and combined adrenal tumor. Cavernous spleen hemangioma, accompanied by destruction of hemopoietic cells, gastrointestinal stromal tumor, and Hailey-Hailey disease, all based on genetic mutations, are rare concomitant diseases in adrenal myelolipoma. Conclusion: Myelolipoma tumorogenesis depends not only on concomitant pathology in adrenal gland but also on myelolipoma association with diseases stimulating histogenesis of both fatty cells and hemopoietic elements.
Almanac of Clinical Medicine. 2014;(32):105-111
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