No 32 (2014)

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 4-10^th 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.

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. 

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.

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.

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.

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.

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.

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 34^th 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).