[Autoimmune polyendocrine syndrome in adults. Focus on rheumatological aspects of the problem: A review]

Autoimmune polyglandular syndromes (APS) are a heterogeneous group of clinical conditions characterized by functional impairment of multiple endocrine glands due to loss of central or peripheral immune tolerance. These syndromes are also often accompanied by autoimmune damage to non-endocrine organs. Taking into account the wide range of components and variants of the disease, APS is usually divided into a rare juvenile type (APS 1) and a more common adult type (APS 2-4). APS type 1 is caused by a monogenic mutation, while APS types 2-4 have a polygenic mode of inheritance. One subtype of adult APS (APS 3D) is characterized by a combination of autoimmune thyroid disease and autoimmune rheumatic disease. This review considers the available literature data on combinations that meet the above criteria. Many studies have noted a significantly higher prevalence of rheumatic diseases in patients with autoimmune thyroid disease compared with the control group. Also, as in a number of rheumatic diseases, a more frequent occurrence of autoimmune thyroiditis, primary hypothyroidism and Graves' disease was noted.

[Assessing of iodine consumption with iodized salt in organized nutrition of children of preschool and school age in the Tyumen region]

The territory of the Tyumen region is an endemic region with insufficient iodine content in the environment, in which, since the early 1990s, active preventive measures have been taken to increase the use of iodized salt (IS) in households, catering and the food industry. The purpose of the research was to assess the consumption of iodine with IS used in the organized nutrition of children in the Tyumen region. Material and methods. The assessment of iodine intake was carried out in preschool institutions and schools randomly selected the city of Tyumen and rural areas (village of Isetskoye). Modeling of iodine consumption in organized groups was carried out for children aged 1-3, 3-7, 7-11 and 12 years and older in urban and rural areas, respectively, using a standard menu and a technological map of dishes. Iodine intake was estimated based on the content of 40 μg of iodine in 1 g of salt and its 30% loss during cooking. Model 1 assumed the mandatory use of IS in the preparation of all salt-containing meals for preschoolers and schoolchildren. Model 2, in addition to the mandatory use of IS in school and preschool meals accounted the consumption of iodine with bakery products (BP) produced with IS. Results. The modeling showed that the average intake of iodine with meals (model 1) in preschool institutions in Tyumen was 89±16 μg/day for children aged 1-3 years. When BP with IS were included in the menu (model 2), iodine intake increased to 101±14 μg/day. In children aged 4-7 years iodine intake was 115±18 and 126±18 μg/day, respectively. In rural areas, iodine intake was lower: in children aged 1-3 years, under model 1, iodine intake was 66±3 μg/day, under model 2 - 76±4 μg/day. In children aged 4-7 years, these figures were 83±3 and 92±4 μg/day, respectively. Iodine consumption in a school in Tyumen under model 1 in children 7-11 years old was 24±5 μg/day, and in children 12 years and older - 27±6 μg/day. When BP with IS were included in the menu (model 2), iodine intake increased to 32±5 μg/day in children 7-11 years old and to 39±6 μg/day in children 12 years of age and older. In rural areas, when using model 1, iodine intake in children aged 7-11 years was 37±15 μg/day, in children aged 12 and over 40±21 μg/day. When BP with IS were included in the menu (model 2), iodine intake increased to 44±15 μg/day in children aged 7-11 years and to 50±21 μg/day in children 12 years of age and older. Conclusion. The use of IS in the preparation of salt-containing meals in preschool educational institutions of the Tyumen region fully covered the iodine requirements of preschool children, which confirms the effectiveness of the chosen strategy for the prevention of iodine deficiency and can be considered as an important part of the concept of universal salt iodization. The use of IS in preparation of school breakfast meals provides 23.5-36.9% of the recommended nutrient intake for iodine in rural schools and 15.4-26.4% of the recommended nutrient intake in urban schools, which can be a significant contribution to the total intake of this micronutrient.

[Resolution on the results of the interdisciplinary expert council "Prevention and treatment of obesity. How to Achieve a Healthy Metabolic Balance]

On September 30, 2022, a meeting of the interdisciplinary expert council "Prevention and treatment of obesity. How to Achieve a Healthy Metabolic Balance. To reduce the social and economic burden of obesity and its consequences in the Russian Federation, it is necessary to introduce socially significant initiatives to prevent obesity and increase its detection rate, as well as to update modern approaches to the treatment of this chronic disease, taking into account its multifactorial pathogenesis, comorbidity, risk of complications and patient disability. Based on the results of the scientific reports and discussions held during the expert council, the experts made decisions on a further plan within the framework of socially significant initiatives for the prevention of obesity.

Atypical and typical course of neurofibromatosis type 1 in combination with pheochromocytoma

Neurofibromatosis type 1 is a hereditary disease that has a multisystem character of organism damage, a wide variability of clinical manifestations, up to the almost complete absence of typical symptoms. Phenotypic manifestations, their expressiveness and heaviness can be varied even among members of the same family with identical mutations. One of the possible clinical manifestations of this pathology is pheochromocytoma, the development of which is associated with a high risk of developing life-threatening conditions. Timely diagnosis of the disease, the choice of treatment tactics for the patient, genetic testing of blood relatives can significantly improve the survival rate and prognosis of the disease. In this article, on the presented clinical examples of patients with a typical and atypical course of type 1 neurofibromatosis in combination with pheochromocytoma, the issues of managing patients with this pathology are outlined.

[The study of blood serum trace elements in comparison with the structural and functional characteristics of goiter and the carriage of antithyroid antibodies in some regions of Russia]

The study of the sufficiency with essential trace elements in the context of thyroid pathology is especially relevant, since the development and progression of thyroid diseases have various pathogenetic mechanisms, which largest proportion is provoked by insufficient intake of key trace elements, primarily iodine. The aim of the research was obtaining primary data on the sufficiency with essential trace elements of the population in the some regions of the Russian Federation, comparing the data obtained with the prevalence of goiter and the carriage of antibodies to thyroid peroxidase (AT-TPO). Material and methods. The Cross-Sectional Population Study was conducted in medical institutions of the Republics of Crimea, Republics of Tuva and Bryansk region (persons applied for outpatient consultations). The scope of the study was 387 people aged 18 to 65 years (the average age was 40±5 years). All of them underwent: collection of medical history, endocrinologist examination with palpation of the thyroid gland (TG), ultrasound examination of TG, blood sampling to assess the levels of thyroid-stimulating hormone (TSH), AT-TPO, iodine, selenium, zinc. Ultrasound of the TG was performed in the supine position using a portable ultrasound machine LOGIQe (China) with a multi-frequency linear probe 10-15 MHz. During the study, the volume of the thyroid gland, the presence of nodular formations and their characteristics according to the TIRADS classification, TG structure and its echogenicity were assessed. Iodine, selenium and zinc level were measured using tandem mass spectrometry with ionization in inductively coupled plasma (Agilent 8900 ICP-MS Triple Quad). TSH and Ab-TPO were determined by chemiluminescent immunoassay on the Architect i2000 automatic analyzer. Results. All regions are comparable in terms of iodine availability, but differ in the severity of natural iodine deficiency. The median concentration of iodine in blood serum practically coincided in all three regions, amounting to 39.8 μg/l in the Republic of Crimea; 38.8 μg/l in the Republic of Tyva and 43.4 μg/l in the Bryansk region. Comparing these results with foreign data, as well as with our results on urinary iodine level, obtained by routine cerium-arsenite method, we can assume that iodine content in blood serum corresponded to the lower limit of the normal target values. The median concentration of selenium in blood serum also practically coincided in all three regions, amounting to 68.2, 72.1 and 62.8 μg/l, respectively, and probably meets the criteria for optimality. The median serum concentration of zinc in Bryansk region residents corresponded to a deficiency (491.3 μg/l) and was significantly lower compared to the indicator in the Republics of Crimea and Tyva (1633.2 and 1667.6 μg/l, respectively, values above optimal). Among the examined, the proportion of people with AB-TPO carriership was 23.5% (Republic of Crimea - 20.9%, Republic of Tuva - 26.4%, Bryansk region - 20.7%), with impaired thyroid function - 9.6% (6.2% - hypothyroidism, 3.4% - thyrotoxicosis). The frequency of goiter varied from 10 to 13.8%. There were no significant differences in the frequency of occurrence, ultrasonic characteristics of goiter and thyroid nodules by regions. Conclusion. However, the results obtained do not allow to unequivocally judge the absence of micronutrient deficiency in the population of the regions of the Russian Federation, since used the ICP-MS method requires the development of our own reference values of trace elements; in the absence of the latter, data from similar foreign studies were taken as standards. In addition, in further studies it will be important to take into account additional criteria for assessing trace element deficiency, for example, activity of superoxide dismutase and alkaline phosphatase as indirect markers of zinc deficiency, etc. Correlation between blood serum concentration of trace elements and the frequency and structural characteristics of goiter, the carriage of Ab-TPO, and dysfunction of the TG was not revealed.

Draft of the clinical practice guidelines “Adrenal incidentaloma”

The wider application and technical improvement of abdominal imaging procedures in recent years has led to an increasingly frequent detection of adrenal gland masses — adrenal incidentaloma, which have become a common clinical problem and need to be investigated for evidence of hormonal hypersecretion and/or malignancy. Clinical guidelines are the main working tool of a practicing physician. Laconic, structured information about a specific nosology, methods of its diagnosis and treatment, based on the principles of evidence-based medicine, make it possible to give answers to questions in a short time, to achieve maximum efficiency and personalization of treatment. These clinical guidelines include data on the prevalence, etiology, radiological features and assessment of hormonal status of adrenal incidentalomas. In addition, this clinical practice guideline provides information on indications for surgery, postoperative rehabilitation and follow-up.

[Iodine Deficiency Disorders: Current State of the Problem in the Bryansk Region]

BACKGROUND

The Bryansk region is one of the regions of the Russian Federation most affected by the accident at the Chernobyl nuclear power plant on April 26, 1986.In the conditions of a chronic uncompensated deficiency of iodine in the diet in the first months after the accident, an active seizure of radioactive iodine by the thyroid tissue took place, which inevitably resulted in an increase in thyroid diseases from the population in the future. The article presents the results of a control and epidemiological study carried out in May 2021 by specialists of the National Medical Research Center of Endocrinology of the Ministry of Health of Russia, aimed at assessing the current state of iodine provision in the population of the Bryansk region.

AIM

Assessment of iodine supply of the population of the Bryansk region.

MATERIALS AND METHODS

The research was carried out in secondary schools of three districts of the Bryansk region (Bryansk, Novozybkov and Klintsy).The study included 337 schoolchildren of pre-pubertal age (8-10 years), all children underwent: measurement of height and weight immediately before the doctor's examination, which included palpation of the thyroid gland (thyroid gland); Thyroid ultrasound using a portable device LOGIQe (China) with a multi-frequency linear transducer 10-15 MHz; determination of iodine concentration in single portions of urine. A qualitative study for the presence of potassium iodate in samples of table salt (n = 344) obtained from households and school canteens was carried out on the spot using the express method.

RESULTS

According to the results of a survey of 337 pre-pubertal children, the median urinary iodine concentration (mCIM) is 98.3 μg / L (range from 91.5 to 111.5 μg / L, the proportion of urine samples with a reduced iodine concentration was 50.1%). According to the ultrasound of the thyroid gland, 17% of the examined children had diffuse goiter, the frequency of which varied from 9.4 to 29% in the areas of study. The share of iodized salt consumed in the families of schoolchildren in the study areas was 17.8% (values range from 15.6 to 19%), which indicates an extremely low level of iodized salt consumption by the population. All salt used for cooking in school canteen areas of the study was iodized, which confirms compliance with the requirements of SanPiN 2.4.5.2409-08.

CONCLUSION

Despite the active implementation in the Bryansk region of various preventive programs of IDD and social activities to promote the use of iodized salt, in the absence of mass prevention with the help of iodized salt to date, their unsatisfactory results should be noted.

INIMITABLE VILEN I. KANDROR

Не бывает незаменимых, но есть неповторимые… Это про Вилена Иосифовича Кандрора,  человека, ученого, профессионала, нашего дорогого  коллегу, с которым мы простились в этом году.

[Clinical practice guidelines "Management of iodine deficiency disorders"]

Iodine deficiency disorders is a sweeping term that includes structural and functional impairment of the thyroid gland.These clinical guidelines include algorithms for the diagnosis and treatment of euthyroid goiter and nodular/ multinodular goiter in adults and children. In addition, these clinical guidelines contain information on methods for an adequate epidemiological assessment of iodine deficiency disorders using such markers as the percentage of goiter in schoolchildren, the median urinary iodine concentration, the level of neonatal TSH, the median thyroglobulin in children and adults. As well from these clinical guidelines, you can get to know the main methods and groups of epidemiological studies of iodine deficiency disorders.

[Clinical practice guidelines for acute and chronic thyroiditis (excluding autoimmune thyroiditis)]

Острые и хронические заболевания щитовидной железы занимают второе место по выявляемости после сахарного диабета. Всемирная организация здравоохранения отмечает ежегодную тенденцию к увеличению числа заболеваний щитовидной железы. В настоящих клинических рекомендациях будут рассмотрены вопросы этиологии, клинического течения, диагностики и лечения острых и хронических (за исключением аутоиммунного) воспалительных заболеваний щитовидной железы.Клинические рекомендации — это основной рабочий инструмент практикующего врача, как специалиста, так и врача узкой практики. Лаконичность, структурированность сведений об определенной нозологии, методов ее диагностики и лечения, базирующихся на принципах доказательной медицины, позволяют в короткий срок дать тот или иной ответ на интересующий вопрос специалисту, добиваться максимальной эффективности и персонализации лечения.Клинические рекомендации составлены профессиональным сообществом узких специалистов, одобрены экспертным советом Министерства здравоохранения РФ. Представленные рекомендации содержат максимально полную информацию, которая требуется на этапе диагностики острых и хронических тиреоидитов, этапе выбора тактики ведения пациентов с тиреоидитом, а также на этапе лечения пациента.Рабочая группа представляет этот проект в профессиональном журнале, посвященном актуальным проблемам эндокринологии, с целью повышения качества оказываемой медицинской помощи, повышения эффективности лечения острых и хронических тиреоидитов путем ознакомления с полным тестом клинических рекомендаций по острым и хроническим тиреоидитам (исключая аутоиммунный тиреоидит) максимально возможного количества специалистов в области не только эндокринологии, но и медицины общей (семейной) практики.

[Dynamics of epidemiological indicators of thyroid pathology in the population of the Russian Federation: analytical report for the period 2009-2018]

ОБОСНОВАНИЕ. Уровень потребления йода населением во многом определяет спектр тиреоидной патологии. На сегодняшний день в РФ йододефицитные заболевания (ЙДЗ) занимают лидирующие позиции в структуре всех заболеваний щитовидной железы (ЩЖ). Хронический дефицит йода (ЙД) приводит к неблагоприятным последствиям для здоровья и существенным экономическим затратам на их устранение в масштабах страны. Кроме того, спектр тиреоидной патологии в условиях ЙД не ограничивается проблемой ЙД, и изучение остальных заболеваний ЩЖ также представляет интерес.ЦЕЛЬ. Проанализировать динамику основных эпидемиологических показателей ЙДЗ и других заболеваний ЩЖ у всего населения РФ за период 2009–2018 гг., используя данные официальной государственной статистики.МЕТОДЫ. Проанализированы заболеваемость и распространенность заболеваний ЩЖ у всего населения РФ с использованием данных официальной государственной статистики. Использованы статистические формы №63 МЗ СР РФ «Сведения о заболеваниях, связанных с микронутриентной недостаточностью» и №12 «Сведения о числе заболеваний, зарегистрированных у больных, проживающих в районе обслуживания лечебного учреждения, РОССТАТ». Анализируемый период — 2009–2018 гг. Для оценки динамики распространенности и заболеваемости были построены линейные регрессионные модели.РЕЗУЛЬТАТЫ. Данные проанализированы в соответствии с представленной в статистической отчетности структурой заболеваний: зоб, тиреоидит, гипотиреоз, тиреотоксикоз, синдром врожденной йодной недостаточности. За десятилетний период 2009–2018 гг. отмечается статистически значимый рост распространенности различных форм зоба, тиреотоксикоза, синдрома врожденной йодной недостаточности у всего населения РФ. В течение периода наблюдения выявлен рост заболеваемости тиреотоксикозом. В отношении заболеваемости синдромом врожденной йодной недостаточности выявлена лишь тенденция к росту. Несмотря на то что в течение периода наблюдения число новых случаев различных форм зоба уменьшилось, распространенность зоба среди населения РФ остается высокой: 1,2% населения к 1 января 2019 г. В отношении тиреоидита выявлен статистически значимый рост распространенности и заболеваемости, что может быть связано с ростом аутоиммунной патологии, совершенствованием уровня диагностики, а также, в некоторых случаях, с гипердиагностикой (например, при постановке диагноза аутоиммунного тиреоидита у лиц с бессимптомным носительством антитиреоидных антител). Существующие на сегодняшний день подходы к йодной профилактике недостаточно эффективны.ЗАКЛЮЧЕНИЕ. Результаты проведенного анализа свидетельствуют преимущественно о росте распространенности тиреоидной патологии среди населения РФ на фоне проводимых региональных мероприятий. Проблема ЙДЗ остается нерешенной, что диктует необходимость внедрения всеобщего обязательного йодирования соли на территории РФ.

[The role of cytokines in the processes of adaptive integration of immune and neuroendocrine reactions of the human body]

Иммунная, эндокринная и нервная системы интегрированы благодаря существованию взаимных путей передачи информации об изменениях их фактического функционального состояния. Главными задачами мозга являются прием, интеграция и хранение информации, и есть убедительные доказательства, что это относится и к информации, полученной с помощью иммунных реакций организма. Доказано, что выработка цитокинов в головном мозге может быть вызвана не только периферической иммунной стимуляцией, но и собственно нервными клетками, стимулированными определенными нейросенсорными сигналами. Эволюционно сохраненные антигомеостатические механизмы, характерные для конкретных заболеваний, — предмет дальнейших исследований, результаты которых могут быть очень важны для разработки терапевтических стратегий, которые препятствовали бы нежелательным комбинированным эффектам иммунных и нейроэндокринных медиаторов.

[Vitamin D deficiency in Russia: the first results of a registered, non-interventional study of the frequency of vitamin D deficiency and insufficiency in various geographic regions of the country]

ОБОСНОВАНИЕ. В Российской Федерации отсутствуют широкомасштабные одномоментные многоцентровые эпидемиологические исследования, оценивающие распространенность дефицита и недостаточности витамина D в различных географических широтах. Недостаточный уровень солнечной инсоляции и неадекватное содержание витамина D в продуктах питания диктуют необходимость изучения эпидемиологической структуры низкого статуса витамина D в России.ЦЕЛЬ. Оценить частоту дефицита и недостаточности витамина D среди населения, проживающего в регионах Российской Федерации, расположенных в широтах от 45° до 70°.МАТЕРИАЛЫ И МЕТОДЫ. Проведен первый этап российского многоцентрового неинтервенционного регистрового исследования по методу «поперечных срезов» с марта 2020 по май 2020 гг.РЕЗУЛЬТАТЫ. В регионах РФ, которые представляют собой репрезентативную с географической точки зрения выборку с высоким риском развития низкого уровня витамина D, его дефицит отмечен в 55,96%, а уровень дефицита и недостаточности регистрируется в 84,01%.ЗАКЛЮЧЕНИЕ. Пристальное внимание к широкому масштабу проблемы дефицита и недостаточности витамина D в РФ будет способствовать прогрессивному формированию различных образовательных и профилактических программ, необходимых для укрепления здоровья и улучшения качества жизни населения.

[Monitoring of iodine deficiency disorders in the Republic of Tyva]

BACKGROUND

The Republic of Tyva is a region with a proven severe natural iodine deficiency and a high prevalence of IDD (iodine deficiency disorders). However, in the region in certain periods of time, measures were taken to eliminate iodine deficiency in the diet of the population. The article presents the results of the October 2020. by specialists of the Endocrinology Research Centre, a control and epidemiological study aimed at assessing the current state of iodine supply in the population of the Republic of Tyva. The study was carried out on behalf of the Ministry of Health of Russia within the framework of the state task «Scientific assessment of the need to take additional regulatory legal and other measures to eliminate iodine deficiency in pilot regions with severe iodine deficiency».

AIM

Assessment of iodine supply of the population of the Republic of Tuva.

MATERIALS AND METHODS

The research was carried out in three settlements of the republic - years. Kyzyl, Shagonar, Saryg-Sep settlement. A total of 227 pre-pubertal schoolchildren (8-10 years old) were examined with anamnesis collection, examination by an endocrinologist, palpation of the thyroid gland, collection of single urine samples into disposable eppendorfs, followed by freezing to minus 20-25 degrees to further determine the concentration of iodine in urine with using the cerium-arsenitic method in the laboratory (clinical diagnostic laboratory of the Federal State Budgetary Institution «National Medical Research Center of Endocrinology» of the Ministry of Health of Russia). In addition, all schoolchildren underwent an ultrasound examination of the thyroid gland (using a portable ultrasound machine LOGIQe (China) with a multifrequency linear transducer 10-15 MHz, in the supine position). The height and weight of children was determined according to the standard method at the time of the examination. A collection of samples of edible salt, which is used in families of schoolchildren, was carried out and the presence of iodine in it was determined by an express method for the qualitative determination of potassium iodate.Parents of schoolchildren signed informed consent for the examination of children. Permission of the local ethical committee of the Endocrinology Research Centre - received, date: March 25, 2020, N 5.

RESULTS

227 schoolchildren of 8-10 years old were examined. The median concentration of iodine in urine was determined, the presence of iodine in food salt was investigated, and an ultrasound examination of the thyroid gland was carried out in order to clarify the iodine supply, the coverage of the use of iodized salt in nutrition and the prevalence of goiter.The median concentration of iodine in urine was 153 μg/l, the frequency of goiter was 7.7%, and the proportion of households using iodized salt was 95.2%.

CONCLUSION

Results of assessment (median urinary iodine concentration) confirm that population of Tuva, Russian Federation, has optimum iodine nutrition. The prevalence of goiter in schoolchildren significantly decreased compared to earlier assessments. The proportion of households using iodized salt indicates the effectiveness of preventive measures in the -region.

[The prospects for the creation of the National Center for Personalized Medicine of Endocrine Diseases]

ФГБУ «НМИЦ эндокринологии» Минздрава России (НМИЦ эндокринологии) получил право реализовать программу развития Научного Центра Мирового Уровня «Национальный Центр Персонализированной медицины эндокринных заболеваний» (НЦПМЭЗ). Задачей НЦПМЭЗ станет не только создание системы персонализированного лечения, но и подготовка новых кадров для медицины. Фундаментальные исследования, проводимые на базе уже существующих институтов и лабораторий НМИЦ эндокринологии, будут расширены за счет создаваемых de novo лабораторий НЦПМЭЗ в соответствии с одобренным проектом.  Данная публикация знакомит читателя с наиболее значимыми лабораториями, которые планируется создать в НЦПМЭЗ: лабораторией общей, молекулярной и популяционной генетики, биоинформатики, фармакогеномики, микробиоты, редактирования генома, математических и цифровых технологий, неинвазивных технологий диагностики эндокринопатий, клеточных технологий, искусственного интеллекта и принципиально новой, не имеющей аналогов, лабораторией метаболической визуализации и радиотераностики.  Авторы надеются, что читатели одного из основных журналов для эндокринологов нашей страны примут активное участие в осуществлении планов НМИЦ эндокринологии, поскольку как у молодых, так и у опытных талантливых исследователей появится шанс стать частью команды Центра. Для выполнения амбициозных задач необходимо кардинально изменить мировоззрение врача в стране, разработать новую систему обучения за счет увеличения числа специалистов по медицинской генетике, транскриптомике, биостатистике и биоинформатике, работающих на стыке экспериментальной и клинической эндокринологии, что обеспечит транзит инновационных технологий в клиническую практику. Созданные лаборатории Научного Центра Мирового Уровня станут местом будничной работы нового поколения врачей, владеющих не только основами клинической работы, но и навыками фундаментальных исследований, что позволит им значительно улучшить методы прогнозирования, диагностики и лечения.

[Vitamin D and pregnancy: current state of the problem in the central regions of the Russian Federation]

BACKGROUND

It has been proven that vitamin D plays an important role in pregnancy. Deficiency of this element may be associated with the risk of developing gestational diabetes mellitus, preeclampsia, placentar insufficiency, low birth weight and premature birth.

AIMS

To conduct an epidemiological analysis of vitamin D supply in women at different stages of pregnancy, living in Russia.

MATERIALS AND METHODS

We included 1198 pregnant women living in 3 regions of Russia in the observational, multicenter, cross-sectional, continuous study. All pregnant women were tested for serum 25(OH)D levels. We collected biomaterial from August 2018 to December 2019. The end point of the study was the indicator of vitamin D supply in pregnant women and its level depending on the trimester of pregnancy and region of Russia. Statistical analysis included counting and grouping according to vitamin D levels, and calculating the median vitamin D concentration in each region.

RESULTS

We confirmed vitamin D deficiency in all regions. The optimum level of this element is present in less than 7% of women. Insufficiency of this element is present in 20,62% of all women. The largest percentage of them is in a deficit of this element - 46,66%. We found that the lowest rates are in Smolensk, where the median was 12,75 ng/ml. In addition, we found changes in vitamin D concentration: with an increase in gestational age revealed a decrease in its level.

CONCLUSIONS

In our study, we confirmed the presence of a 25(OH)D deficiency in most of the examined pregnant women, which is consistent with international epidemiological data. We should remember about these both at the stage of pre-gravid preparation and at the stage of pregnancy itself in order to achieve the optimal level of vitamin D.

[The prevalence of autoimmune endocrine diseases in vitiligo patients]

Vitiligo is a common polygenic autoimmune disease in which the foci of depigmentation are formed on the skin and/or mucous membranes as a result of the death of melanocytes. There are several hypotheses for the pathogenesis of the disease, the leading role among them is played the autoimmune hypothesis. This review summarizes the available literature data on the prevalence and structure of comorbid endocrine autoimmune pathology in vitiligo patients. In most studies conducted in Europe, America and Asia the prevalence of autoimmune thyroid diseases (including autoimmune thyroiditis and Graves disease), diabetes mellitus and autoimmune adrenal insufficiency was higher in vitiligo patients than in the general population. The results of some studies indicate a frequent association of vitiligo with autoimmune polyglandular syndromes. In the structure of comorbid pathology the highest prevalence was in autoimmune thyroid diseases. A number of studies have established a higher prevalence of autoimmune endocrine diseases in women, as well as in nonsegmental vitiligo patients and in cases of family history of vitiligo and/or other autoimmune diseases. In addition, it was shown that the prevalence of endocrine diseases increases with increasing area of depigmentation. The data obtained justify the advisability of conducting a timely examination of vitiligo patients with the aim of early detection of comorbid diseases and the appointment of appropriate treatment. Further studies are needed to investigate the effect of the identified associations on the course of vitiligo and comorbid endocrinopathies, as well as the effectiveness of therapy and the quality of life of patients.

[The prevalence of newly diagnosed autoimmune diseases among patients with Graves' disease and autoimmune polyglandular syndrome of adults]

Gravess disease is a common part of Autoimmune polyglandular syndrome (APS) and among thyroid autoimmune disorders is usually preceded the onset of the syndrome.

AIM

The aim of this study was to determine the frequency of occurrence of APS type 2, 3 among patients with Graves disease.

MATERIALS AND METHODS

Sera of 94 patients with Gravess disease, 116 patients with APS 24 types and 80 healthy subjects were screened for 21-OH Ab, insulin-Ab (IAA), Islet Cell-Ab (ICA), glutamic acid decarboxylase-Ab (GADA), protein tyrosine phosphatase-Ab (IA2), Zinc Transporter 8-Ab (ZnT8), Anti-gliadin-Ab (IgA+IgG) (AGA), Anti-transglutaminase-Ab (IgA+IgG) (Anti-tTG), Anti-parietal cell-Ab (APCA), Intrinsic Factor-Ab (IF), Rheumatoid factor (RF), Anti Ovarian Antibodies (AOA). Serum cortisol, fasting plasma glucose levels were measured.

RESULTS

The presence of Addisons disease and the onset of Type 1 DM was not determined among Graves disease patients. None of the patients with Graves disease and in the healthy control group had 21-OH-antibodies detected. The frequency of 21-OH-Ab was 4.2% in APS type 3 (p=0.07) and 91.6% in APS type 2, 4 (p0.001). The prevalence of diabetes-associated autoantibodies was 20.2% among Gravess disease patients against 8.75% in healthy subjects control group (p0.05); OR 2.64; 95% CI 1.056.66 and 30.2% in APS of adults (DM 1 negative group) (p=0.18). The prevalence of APCA-markers of autoimmune gastritis was 31.9% in Gravess disease, 48.3% in APS 24 types (p=0.01); OR 1.99; 95% CI 1.183.51, and 12.5% in control group (p0.01); OR 3.28; 95% CI 1.497.24. There were no significant differences in the frequency of occurrence of IF-Ab and RF-Ab in the groups. The frequency of AGA and ATA was 28.7% in Graves disease, 36.2% in APS types 24 (p=0.3), 10% in the control group ((р0.01); OR 3.63; 95% CI 1.548.54. Graves disease patients with risk of developing APS type 3 (positive diabetes-associated and other autoantibodies) had relatives with autoimmune diseases in 57.5% of cases (p=0.05); OR 2.18; 95% CI 1.034.63.

CONCLUSION

Graves disease patients are at high risk for future development of APS 3 type, especially those with inheritance for autoimmune diseases. Screening for the immunological markers, pathognomonic for coexisting autoimmune diseases in such patients with Graves disease, as well as in patients with APS type 3, should be done regularly.

[Iodine deficiency disorders as a non-infectious epidemic: a look at the problem at the tome of COVID-19 pandemic]

Radioactive iodine, flying out of the destroyed reactor of the Chernobyl nuclear power plant, like a corona virus quickly spread throughout Europe. Iodine deficiency in the regions of Ukraine, Belarus and Russia adjacent to nuclear power plants became a factor in increased uptake of radioactive iodine by the thyroid gland in children and after 5 years led to an epidemic of thyroid cancer. Optimal iodine intake could become a kind of vaccination, which sharply reduces the risk of developing thyroid cancer, as has happened after the accident at the Fukushima nuclear power plant in Japan. Endemic goiter was eliminated 50 years ago, but returned to the country in the early 1990s after the collapse of iodized salt production and has not been eliminated to this day due to the lack of a legislative framework for mandatory salt iodization. The actual average consumption of iodine by residents of Russia is from 40 to 80 mcg per day, which is 23 times less than the recommended norm. Mild and moderate iodine deficiency was detected throughout the Russian Federation, and it is more typical for the the rural population. The iodine deficiency has the greatest negative effect on the psychomotor development of the child during the critical period the first 1000 days of life from the moment of conception to the end of the second year of life. According to WHO, over the past 20 years, iodine deficiency has been eliminated in 115 countries of the world, and the number of iodine-deficient countries has dropped to 25, but Russia is still among them. We believe that after the COVID-19 pandemic, it will no longer be necessary to prove the need for effective support for the prevention of both infectious and non-infectious diseases, and the declared preventive direction of Russian medicine will indeed become such.

[The development of Graves' disease after long-term hypothyroidism due to Hashimoto's disease]

The main autoimmune thyroid diseases are Hashimoto's thyroiditis (HT) and Graves' disease (GD). Despite the significant differences in a pathogenesis and a clinical picture between HT and GD, the literature describes the cases of the conversion of one autoimmune disease to another, which, according to one version, is associated with a change in the balance between the levels of a stimulating and blocking antibodies to the thyroid-stimulating hormone receptor. At the same time, there are more frequent observations of the transition of GD to HT, and much less often describe, on the contrary, the development of GD against the background of HT. The article presents a clinical case of the conversion of HT to GD. A detailed algorithm of the conservative management according to the «block-replace» scheme is described, indicating the results of laboratory and instrumental examination. At the time of describing the clinical case, the result of the treatment can be considered successful. The predictors such as a low level of the thyroid-stimulating hormone receptor and thyroid volume before discontinuation of the thyrostatic therapy suggest a low risk of the recrudescence of GD.According to the authors, the phenomenon of the conversion of one autoimmune thyroid disease to another, in addition to the scientific interest, is important for the practitioners, since a timely change in the diagnostic paradigm can significantly change the treatment strategy and the favorably affect the prognosis of disease, preventing the development of complications.

[Clinical case report: history of diagnosis and clinical features of type autoimmune polyglandular syndrome 1]

Autoimmune polyglandular syndrome type 1 (APS-1) is a rare disease with autosomal recessive inheritance and it caused by mutations in the autoimmune regulator (AIRE) gene. This disease has clinical polymorphism that including besides endocrinopathies other organ-specific manifestations and that complicates to diagnose of this condition on time. However, most often APS-1 has a characteristic debut and a certain stage of clinical symptom manifestation. This article describes a case report of an 18-year-old patient with confirmed APS-1, in which the course of disease was erased over a long period of life and didnt meet of clinical criteria for the diagnosis in this syndrome. A high quality of life for such patients is possible with timely, individually selected replacement therapy with subsequent follow-up. It is important to remember the need for screening in risk groups for the formation of clinical forms of APS among the subjects presenting with a single endocrine pathology. The continuity of medical supervision by pediatric and adult endocrinological service physicians must be respected that can be traced on the example of the case from our practice.

[Primary hyperaldosteronism: difficulties in diagnosis]

Primary hyperaldosteronism (PA) - is the clinical syndrome, results from autonomous of the major regulators of secretion, aldosterone overproduction by a tumorous or hyperplastic tissue in adrenal cortex. Being the most frequent cause of secondary hypertension, PA may be represented by disorders with unilateral or bilateral aldosterone overproduction and differential diagnosis between them is crucial for choosing a right therapeutic approache: lifelong medical therapy with mineralocorticoid receptor antagonists or unilateral adrenalectomy. Adrenal venous sampling (AVS) is currently the «gold standard» test for identifying laterality of excess hormone production, unlike imaging tests, sensitivity and specificity of which is not enough, due to inability to evaluate functional activity with confidence, and also to limitations in detecting tiny abnormalities of adrenals, such as microadenoma or hyperplasia. Excluding certain cases, AVS is recommended to patients with confirmed PA, planning surgical treatment, to determine the lateralization of aldosterone hypersecretion. Described clinical case of patient with confirmed lateralization from adrenal without any detected lesions on CT-imaging and nonfunctioning tumour on contralateral side, highlights the importance of using AVS for decision to refer patients for surgery.

[Autoimmune polyglandular disorders in myotonic dystrophy]

Myotonic dystrophy (MD) is the most common muscle disorder in adults. MD is a hereditary disease with an autosomal dominant mode of inheritance, almost 100% penetrance and pronounced clinical polymorphism. The mechanism for the development of the disease is that a mutation of the DMPK (dystrophia myotonica protein kinase) gene disrupts the normal metabolism of RNA, which leads to a defect in the maturation and translation of mRNA. The disorder in the DMPK gene affects not only striated musculature, but also smooth myocytes and cardiomyocytes. The main clinical symptom that distinguishes MD from others is a spontaneous or provoked inability to relax muscles (myotonia phenomenon). Endocrine disorders arising from type 1 MD (MD1) with a higher than average frequency in the population include hypergonadotropic hypogonadism, impaired glucose tolerance with hyperinsulinism, and insulin resistance. Thyroid function may remain normal, although many cases of autoimmune thyroiditis resulting in hypothyroidism, as well as Graves' disease, have been described. A description is given of a patient suffering from MD1 with a number of endocrine disorders, including hypergonadotropic hypogonadism, autoimmune thyroid disease, hyperinsulinism, and also impaired calcium-phosphorus metabolism. Important features are the absence of any significant complaints from the muscular system in the presence of an increase in creatine phosphokinase (CPK), which is characteristic of this disease, as well as the temporal dynamics of thyroid status and the nature of the autoimmune thyroid disease.

[Differential diagnosis between autoimmune thyrotoxicosis and thyroid hormone resistance syndrome: clinical case report]

We report a case of 50-year-old woman with thyroid hormone resistance syndrome. For 20 years this patient have been treated for autoimmune thyrotoxicosis: she underwent thyroid surgery and then was on thyroid-blocking therapy. Repeated laboratory tests demonstrated elevated serum thyroid hormones concentrations and elevated TSH concentration. Inappropriate TSH secretion became the reason for conducting further investigations. In those cases, the diagnostic approach is complicated and cases may be referred as a syndrome of thyroid hormones resistance or as a pituitary mass. Results of magnetic resonance imaging as well as results of octreotide test did not confirm TSH-producing pituitary adenoma. Lack of consistent thyrotoxicosis symptoms and normal level of biochemical markers that reflect peripheral tissue response to excessive thyroid hormones action were regarded as an evidence for thyroid hormones resistance syndrome. In cases of thyroid hormone resistance syndrome, there is no reduction in thyroid hormones after octreotide administration and we could observe it in our patient. Thereby clinical data and laboratory tests supported the diagnosis of thyroid hormone resistance syndrome. To establish definitive diagnosis and to verify genetic cause of the disease we performed direct sequencing of the THRB gene exons 9-10.

[Aldosterone- and cortisol-co-secreting adrenal tumors: an uneasy sum of well-known parts (review)]

Primary aldosteronism (PA) is the most common form of secondary arterial hypertension. In patients with PA, more so than in the general population, there is a prevalence of insulin resistance, diabetes mellitus, metabolic syndrome, osteoporosis, and symptoms of depression; these conditions are more likely to manifest a gluco- rather than mineralocorticoid excess. This fact is of particular importance in light of recent studies that have shown that PA is often associated with glucocorticoid excess. Since the first reports of cases of combined secretion of aldosterone and cortisol in 1979, the number of cases of so-called Connshing syndrome has increased. An analysis of data from recent studies suggests that hypercortisolism in PA is closely associated with an increased risk of cardiovascular complications, metabolic disorders and post-surgical adrenal insufficiency. The most important diagnostic problem in adenomas with combined secretion is the risk of false interpretation of the results of adrenal venous sampling (AVS). The indications that suggest aldosterone-and-cortisol-co-producing adenoma are the lack of suppression of cortisol levels following a night test with 1mg of dexamethasone, and an adrenal tumo of over 2.5cm. As an alternative test capable of differentiating this type of tumor, a number of researchers have proposed measuring the level of so-called hybrid steroids in the peripheral plasma and urine. Taking into account the high prevalence and potential risks, ruling out of excess corisol secretion is obligatory in all cases of PA before AVS and when planning surgery.

The association between the development of autoimmune polyglandular syndrome in adults and polymorphism of HLA class II genes and the predisposition to the development of chronic adrenal insufficiency in the context of these syndromes

AIM

To consider association of chronic adrenal insufficiency in patients with APS of adults with polymorphism of class II HLA genes, -CTLA-4 and PTPN-22.

MATERIALS AND METHODS

The case-control study involved 78 patients with APS 2, 3, 4 types and 109 healthy subjects). Alleles of the HLA class II genes, CTLA-4 and PTPN-22 were identified by the multiprimer allele-specific PCR method. The statistical analysis was carried out using the exact two-sided Fisher test. The association of the chronic adrenal insufficiency in patients with APS was determined by the value of the odds ratio (OR - odd's ratio), the value of 95% confidence interval (95% CI - confidence interval).

RESULTS

Haplotypes DR3-DQ2 (OR = 4.06), DR4-DQ8 (OR = 5.78), genotype DR3/DR4 (OR = 19.7), DQA1 * 0301 allele (OR = 4.27), as well as genotype DQA1 * 0301 / DQA1 * 0501 (OR = 13.89) predispose to the development of APS of adults compared to the control group. APS patients were divided into two groups according to the presence of chronic adrenal insufficiency (APS 2 and 4 types - in one group and type 3 APS in the other group). Haplotype DR3-DQ2 (DRB1 * 17-DQA1 * 0501 -DQB1 * 0201) (OR = 2.6), as well as the genotype DR3/DR4 (OR = 4.28) found the strongest association with the development of adrenal insufficiency in patients with APS of adults. Protective haplotypes DRB1 * 01-DQA1 * 0101-DQB1 * 0501 (p<0.01, OR = 0.07), as well as the DRB1 * 01 allele (p<0.01, OR = 0.08) have been identified with respect to the development of adrenal insufficiency in adult APS patients.

CONCLUSION

Examination of patients with APS of adults without chronic adrenal insufficiency for the presence of protective genes for the development of adrenal insufficiency will allow better predicting the risks of developing of the disease within the syndrome.

The association between the development of autoimmune polyglandular syndrome in adults and polymorphism of HLA class II genes and the predisposition to the development of chronic adrenal insufficiency in the context of these syndromes

Aim: to consider association of chronic adrenal insufficiency in patients with APS of adults with polymorphism of class II HLA genes, CTLA-4 and PTPN-22. Materials and methods. The case-control study involved 78 patients with APS 2, 3, 4 types and 109 healthy subjects). Alleles of the HLA class II genes, CTLA-4 and PTPN-22 were identified by the multiprimer allele-specific PCR method. The statistical analysis was carried out using the exact two-sided Fisher test. The association of the chronic adrenal insufficiency in patients with APS was determined by the value of the odds ratio (OR - odd's ratio), the value of 95% confidence interval (95% CI - confidence interval). Results and discussion. Haplotypes DR3-DQ2 (OR = 4.06), DR4-DQ8 (OR = 5.78), genotype DR3/DR4 (OR = 19.7), DQA1 * 0301 allele (OR = 4.27), as well as genotype DQA1 * 0301 / DQA1 * 0501 (OR = 13.89) predispose to the development of APS of adults compared to the control group. APS patients were divided into two groups according to the presence of chronic adrenal insufficiency (APS 2 and 4 types - in one group and type 3 APS in the other group). Haplotype DR3-DQ2 (DRB1 * 17-DQA1 * 0501 -DQB1 * 0201) (OR = 2.6), as well as the genotype DR3/DR4 (OR = 4.28) found the strongest association with the development of adrenal insufficiency in patients with APS of adults. Protective haplotypes DRB1 * 01-DQA1 * 0101-DQB1 * 0501 (p

[Incretin secretion and glucose metabolism in morbidly obese patients in the early and late periods after biliopancreatic diversion]

AIM

To estimate the parameters of glucose metabolism and to assess the secretion of incretins in patients after biliopancreatic diversion (BPD) for morbid obesity (MO) in the early and late postoperative periods.

SUBJECTS AND METHODS

The prospective part of the investigation included 22 patients with a body mass index of 35.8 to 68.4 kg/m2 and type 2 diabetes mellitus (T2DM). All the patients were examined before, 3 weeks and 3 months after BPD. The retrospective part covered 23 patients who were examined after BPD for MO; the postoperative period was 4.7 [2.3; 7.2] years. A control group consisted of 22 healthy, normal weight volunteers. A 75-g oral glucose tolerance test was carried out in all the groups to study the levels of glucose, immunoreactive insulin (IRI), glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP) and glucagon at 0, 30, 60, and 120 min.

RESULTS

T2DM patients showed improvement in glucose metabolism just 3 weeks after BPD; following 3 months, they had normalized fasting blood glucose levels (5.6 [5.0; 6.0] mmol/l). During 3 months, glycated hemoglobin decreased from 7.5 [6.6; 8.5] to 5.7 [5.3; 5.9]%. In the early period following BPD, there was an increase in basal and postprandial GLP-1 levels associated with the peak IRI concentration. In the late period after BPD, the enhanced secretion of IRI and GLP-1 persisted, which was followed by a reduction in postprandial glucose levels in 4 of the 23 patients.

CONCLUSION

T2DM remission does not depend on weight loss in the early period after BPD. In this period, the significant improvement of glucose metabolic parameters in patients with obesity and T2DM is associated with elevated GLP-1 levels. The altered incretin response is a stable effect of BPD and remains in its late period.

[MiRNAs in the diagnosis of cardiovascular diseases associated with type 2 diabetes mellitus and obesity]

Worldwide, the number of patients with type 2 diabetes mellitus (T2DM), obesity, and cardiovascular diseases (CVD) continues to increase steadily. Despite long-term studies of obesity and concomitant diseases, the molecular genetic bases for the development of these pathological conditions have remained the subject of numerous investigations so far. Recent investigations point to the involvement of miRNAs as dynamic modifiers of the pathogenesis of various pathological conditions, including obesity, T2DM, and CVD. MicroRNAs are involved in various biological processes underlying the development of CVDs, including endothelial dysfunction, cell adhesion, and atherosclerotic plaque formation and rupture. Some of them are considered as potential sensitive diagnostic markers of coronary heart disease and acute myocardial infarction. Approximately 1,000 microRNAs are found in the human body. It has been determined that miRNAs regulate 30% of all human genes. Among them there are about 50 circulating miRNAs presumably associated with cardiovascular diseases. This review provides recent data on the participation of some miRNAs in various pathological and physiological states associated with CVD in DM and obesity. An extended and exact understanding of the function of miRNAs in the gene regulatory networks associated with cardiovascular risk in obesity will be able to reveal new mechanisms for the progression of disease, to predict its development, and to elaborate innovative therapeutic strategies.

[Hereditary pheochromocytoma-associated syndromes. Part 1]

Pheochromocytoma (PCC)/paraganglioma is a catecholamine-secreting tumor of the paraganglion. The hereditary variants of PCC have been previously considered to occur in 10% of cases. The latest researches have clearly demonstrated that the hereditary cause of chromaffin tumors is revealed in a much larger number of patients. There have been the most investigated NF, RET, VHL, SDHD, SDHC, and SDHB gene mutations. New EGLN1/PHD2, KIF1B, SDH5/SDHAF2, IDH1, TMEM127, SDHA, MAX, and HIF2A gene mutations have been recently discovered. This review describes new ideas of the genetic bases of PCC. The authors discuss criteria for patient referral for genetic examination on the basis of the phenotypic.manifestations of mutations, such as a malignant course, bilateral adrenal lesion, and age at disease manifestations. Recommendations are determined for carriers to screen for the components of hereditary pathology.

[Adrenocortical oncocytoma]

The paper characterizes adrenocortical oncocytoma, a rare adrenal tumor, accompanied by Cushing's syndrome and estrogen and androgen production and provides histological and immunohistochemical features. The authors describe their observation of a 33-year-old female woman. It is shown that estimation of the malignant potential of adrenocortical oncocytomas requires a special approach and must be done using the Lin-Weiss-Bisceglia criteria.

[Adrenocortical oncocytoma]

The paper characterizes adrenocortical oncocytoma, a rare adrenal tumor, accompanied by Cushing's syndrome and estrogen and androgen production and provides histological and immunohistochemical features. The authors describe their observation of a 33-year-old female woman. It is shown that estimation of the malignant potential of adrenocortical oncocytomas requires a special approach and must be done using the Lin-Weiss-Bisceglia criteria.

Federal clinical recommendations on diagnostics and treatment of endocrine ophthalmopathy associated with autoimmune thyroid pathology

Endocrine ophthalmopathy (EOP) is a multidisciplinary problem at the intersection of endocrinology and ophthalmology. The patients presenting with this condition experience deficit of adequate medical aid due to the poor cooperation between ophthalmologists and endocrinologists. There are practically no specialized centres in this country where the patients with EOP could receive the combined treatment of this pathology including the surgical intervention. Taken together, late diagnostics and delayed seeking the efficacious medical assistance, the absence of stable compensation of the functional disorders of the thyroid gland, erroneous identification of the phase of the disease, and incorrect choice of the methods for its treatment, the lack of coordination and consistency in the actions of ophthalmologists and endocrinologists are responsible for the low effectiveness of EOP treatment. On the other hand, the absence of the unified approach to diagnostics and treatment of endocrine ophthalmopathy, the necessity of introducing the international experience gained in this field into the routine clinical practice and pooling efforts of representatives of different medical disciplines (endocrinologists, ophthalmologists, radiologists, endocrine surgeons, and neurosurgeons) created the prerequisites for the solution of the EOP problems and gave impetus to the development of the recommendations being proposed.

[Hereditary pheochromocytoma-associated syndromes. Part 2]

Pheochromocytoma (PCC)/paraganglioma is a catecholamine-secreting tumor of the paraganglion. The hereditary variants of PCC have been previously considered to occur in 10% of cases. The latest researches have clearly demonstrated that the hereditary cause of chromaffin tumors is revealed in a much larger number of patients. There have been the most investigated NF, RET, VHL, SDHD, SDHC, and SDHB gene mutations. New EGLN1/PHD2, KIF1В, SDH5/SDHAF2, IDH1, TMEM127, SDHA, MAX, and HIF2А gene mutations have been recently discovered. This review describes the most common PCC-associated syndromes in detail and considers the specific features of new mutations.

[SPECIFIC CLINICAL FEATURES OF TYPE 1 AUTOIMMUNE POLYGLANDULAR SYNDROME]

Autoimmune polyglandular syndrome is a primary autoimmune disorder affecting two or more peripheral endocrine glands and responsible for their incompetence. It is frequently combined with various organ-specific non-endocrine diseases. Patients with this pathology need life-long replacement therapy and dynamic observation by endocrinologists and other specialists to monitor the effectiveness of the treatment and detect new components of the disease. We report a variant of type 1 autoimmune polyglandular syndrome. Special emphasis is laid on the importance of succession of actions of endocrinologists and specialists in related medical disciplines dealing with children and adult patients.

Autoimmune polyglandular syndromes in the adults: the genetic and immunological diagnostic criteria

At present, four main types of autoimmune polyglandular syndromes (APS) are distinguished. Type 1 APS is associated with candidiasis, primary hypoparathyroidism, and primary adrenal insufficiency developing in the childhood as a result of mutations in the AIRE gene. Type 2 APS involves primary adrenal insufficiency in combination with autoimmune thyroid diseases and/or type 1 diabetes mellitus. Type 3 APS is characterized by the combination of autoimmune thyroid diseases with other endocrine and non-endocrine autoimmune pathologies in the absence of adrenal cortical dysfunction and hypoparathyriodism. Type 4 APS is presented by the combinations of autoimmune diseases other than the aforementioned ones. The above syndromes usually manifest themselves at the age between 20 and 60 years; they are of the polygenic type and associated with the genetic markers, such as HLAII-complex haplotypes, CTLA-4, PTPN22, FOXP3 genes, etc. In addition, the latent forms of APS have been described that occur in the populations much more frequently than the manifest disorders. These latent diseases can exert strong influence on the compensation and risk of complications of the underlying pathology. Of great importance in this context is the timely identification of the groups of patients at risk of developing clinical forms of APS among the subjects presenting with a single endocrine pathology.

[Thyroid dysfunction and the hemostatic system]

Whether there is a link between thyroid dysfunction and different impairments in the hemostatic system is discussed. The level of thyroid hormones is an essential factor that influences the coagulation system. Thyroid dysfunction affects the balance between coagulation and fibrinolysis, by increasing the risk of thrombosis and hemorrhage in hyperthyroidism. However, there is no consensus of opinion regarding the mechanisms of the described hemostatic changes in the literature.

[Adiponectin and parameters of glucose and lipid metabolism at different clinical and morphological stages of non-alcoholic fatty liver disease in patients with abdominal obesity]

AIM

To compare clinical, laboratory, and morphological parameters in patients with abdominal obesity and non-alcoholic fatty liver disease (NAFLD) and to assess the relationship between the degree and stage of the disease and the cardiometabolic risk factors of type 2 diabetes mellitus and cardiovascular diseases.

SUBJECTS AND METHODS

Eighty patients aged 30 to 50 years with abdominal obesity were examined. NAFLD was diagnosed after liver puncture biopsy. The parameters of carbohydrate and lipid metabolism and the activity of hepatic transaminases and the protective adipocytokine adiponectin were investigated.

RESULTS

NAFLD was verified in 77 examinees. Metabolic disturbances were found in the majority of the examinees with abdominal obesity and NAFLD; they were concurrent and increased in their rate and degree with the progression of NAFLD, obesity, and insulin resistance. The patients with NAFLD had a significantly decreased adiponectin level that got worse as NAFLD progressed.

CONCLUSION

The investigation has revealed that NAFLD is associated with cardiometabolic disorders (dyslipidemia, carbohydrate metabolic disturbances, and insulin resistance) increasing in their rate and degree with the progression of NAFLD and the lower adiponectin level reducing as NAFLD worsens.

[Latent forms of adult-onset autoimmune polyglandular syndrome: diagnosis and management of patients]

Autoimmune polyglandular syndromes (APS) are an autoimmune involvement of two or more endocrine glands, which are characterized by multiple organ dysfunction. Four major types of APS are presently identified. There are APS types 2, 3, and 4 in adults. There are also latent and incomplete forms of adult-onset APS, the prevalence of which in the population is well above that of clinically apparent diseases. Latent disease may strongly affect the compensation and risk of complications of the underlying condition. The examination of APS risk-group patients includes the detection of genetic (HLA Class II haplotypes, CTLA-4, PTPN22, and FOXP3 genes, etc.) and immunological (antibodies) markers in autoimmune diseases and the determination of the residual function of the target organ. the treatment of autoimmune diseases in adult-onset APS is based on general principles; however, there are a number of specific features of using drugs for the concurrence of a few endocrine diseases. In this connection, the timely identification of risk groups for developing the clinical forms of APS in patients with one autoimmune endocrine disease.

[Abnormal calcium metabolism in the remote period after bariatric surgery]

Calcium metabolism in the long-term period after bariatric surgery is reviewed in the present article. The study of calcium metabolism parameters and vitamin D status was performed in The Endocrinology Research Center. Morbidly obese patients (BMI > 40) were included in the 1st group (n = 22), patients who underwent biliopancreatic diversion for morbid obesity (n = 23) were included in the 2nd group, healthy normal weight controls (n = 22) were included in the 3rd group. 25 (OH) D level was different in the 3 groups (p < 0.001). Vitamin D deficiency prevailed in morbidly obese patients compared to healthy controls (p = 0.007). Elevated parathyroid hormone (PTH) level was found in 4 (18%) morbidly obese patients, in 12 (52%) operated patients. Not a single case of PTH over reference interval was found in the controls. The frequency of secondary hyperparathyroidism was significantly higher in the operated patients.

Primary idiopathic hyperaldosteronism in clinical practice

Primary hyperaldosteronism (PHA) is a clinical syndrome that develops as a result of excess production of aldosterone by adrenal glomerular zone, where aldosterone secretion is completely or partially autonomous in relation to the renin-angiotensin system. This factor leads to the development low renin arterial hypertension (AH). Primary idiopathic hyperaldosteronism is one of the forms of PHA. The prevalence of this form is variously estimated from 20 to 55% of patients with PHA. Morphological substrate primary idiopathic hyperaldosteronism is a bilateral micro- or macronodular adrenal hyperplasia. This article summarizes the contemporary view of the pathogenesis, clinical presentation, diagnosis and treatment of idiopathic hyperaldosteronism.

[Diagnostics and treatment of polyglandular syndrome of adults]

Autoimmune polyendocrine syndromes (APS) are rare endocrinopathies characterized by the coexistence of at least two glandular autoimmune diseases. APS comprise a wide spectrum of autoimmune disorders and are divided into a very rare juvenile (APS type 1) and a more common adult type with (APS 2) or without adrenal failure (APS 3). The first clinical manifestations of APS 1 usually occur in childhood whereas APS 2 mostly occurs during the third and fourth decades of life. The third type has been described in adults that, contrary to types 1 and 2, does not involve the adrenal cortex. No clinical differences between types 2 and 3 have been described except the absence of adrenal failure. Type 4 APS is a rare syndrome characterized by the combination of autoimmune conditions not falling into the above categories. It consists of adrenal failure with one or more minor autoimmune disorders barring major components of type 1 and 2 APS. Usually, autoimmune polyendocrine syndrome of adults manifests itself as one of the major autoimmune diseases (such as adrenal failure, Grave's disease, or type 1 diabetes) and minor autoimmune disorders (vitiligo, alopecia) preceding the development of autoimmune deficiency of major endocrine glands. This article describes a patient with type 3 APS, who developed type 1 diabetes. Grave's disease and vitiligo. The development of the syndrome started from vitiligo in the chidhood. Moreover, the patient suffered primary sterility and presented with progressive diabetic nephropathy of autoimmune origin. It is concluded that patients with a single autoimmune component of polyendocrine syndrome should be screened to exclude other autoimmune endocrine disorders.

[Atypical clinical course of Cushing's disease]

Endogenous hypercorticism is a severe endocrine disease with clinical symptoms resulting from long-term action of corticosteroids. In this country, conditions caused by the excess pituitary ACTH production are called Itsenko-Cushing disease. In the absence of adequate treatment, half of the patients die within 5 years after the onset of the disease. Correct diagnosis prior to the development of severe complications significantly improves its prognosis and patients' quality of life. It is generally believed that endogenous hypercorticosm must be accompanied by pathognomonic symptoms that may be helpful in establishing the diagnosis. However, certain patients present with non-specific symptoms of little diagnostic value. We report a case of Itsenko-Cushing disease lacking in specific symptoms of hypercorticism.

[Graves' disease and pregnancy]

Thyvrotoxicosis is a clinical syndrome related to the negative influence of excess thyroid hormones. Its main cause in young and mid-aged patients is Graves' disease. Therapy with thyrostatic medications are most frequently used in this country as the primary method for the treatment of this disease. The experience of both Russian and foreign authors indicate that 70% of Graves' disease cases require radical treatment. Special caution is needed in the choice of therapies for young women planning pregnancy. Graves'disease developing prior to pregnancy is a contraindication for it because of high risk of its interruption and complications. Such women should be recommended careful contraception. A 27-year-old patient with Graves' disease is described who planned pregnancy and received conservative therapy for an unnecessary, long time. Therapy of thyrotoxicosis during pregnancy and after it is described.

[The saliva cortisol level test using the automatic immunochemical analyzer Cobas e601 (Roche) to diagnose endogenous hypercorticalism in patients with obesity]

The saliva cortisol level test applies to diagnose endogenous hypercorticalism. However the methods of die format immunoassay traditionally used do not make it possible to get the study results on-the-fly. Also, reference interval and optimal takeoffs differ under implementing various techniques of cortisol tests. The purpose of actual study is to investigate the possibilities of electrochemiluminescent technique of testing free cortisol in saliva. The device Cobas e601 was applied to diagnose endogenous hypercorticalism in patients with obesity. The saliva samples were collected at 11 PM from 98 healthy volunteers and 123 patients with obesity (in 45 cases endogenous hypercorticalism was diagnosed). In total, 205 persons donated saliva at 11 PM two days running to evaluate the technique reproducibility. The samples of 197 individuals were frozen to implement the immune-enzyme assay. The minor test with dexamethasone was applied to patients with suspected endogenous hypercorticalism. The diagnosis of endogenous hypercorticalism was finally confirmed after the results of histological analysis of post-operative material or autopsy. Among healthy volunteers, the reference interval on indicators consisted 0.5-9.4 nMol/l. The correlation coefficient under free cortisol measuring at the same time two days running was -0.785. The optimal takeoff to diagnose endogenous hypercorticalism in patients with obesity consisted 9.4 nMol/l, sensitivity--84.4% (95% confidence band 71.2-92.2%), specificity--92.3% (95% confidence band 84.2-96.4%), predictive value of positive result--11.0 (95% confidence band 5.0-23.9), predictive value of negative result--0.17 (95% confidence band 0.08-0.33) and likelihood ratio for positive result--65.1 (95% confidence band 20.4-207.6). The two-fold cortisol test in saliva using immune-enzyme assay and minor test with dexamethasone with their diagnostic capabilities corresponded to one-fold saliva free cortisol test using electrochemiluminescent technique. The one-fold free cortisol test in saliva collected in 11 PM using the analyzer Cobas e601 for electrochemiluminescent immunoanalysis is a convenient and informative endogenous hypercorticalism screening technique in patients with obesity.

[Prevention of iodine deficiency diseases in pregnant and lactating women]

The objective of this work was to evaluate results of control epidemiological studies of iodine-deficiency condition in pregnant and breast-feeding women; the secondary objective was to develop standard prophylactic iodine dose schedule for these patients. The study included two groups of pregnant women treated either with a daily dose of 200 mcg potassium iodide (group 1, n=52) or with 300 mcg Kl/day (group 2, n=69). In all of them, blood TSH, free thyroxin and antithyroid peroxidase antibody levels were measured along with iodine excretion in urine. Thyroid volume was determined by ultrasound. Initially, median urinary iodine excretion in all the patients was 62.7 mcg/l. Three months after onset of the treatment with potassium iodide it significantly increased to 83.5 mcg/l and 1120.8 mcg/l in groups 1 and 2 respectively (p = 0.006 and 0.001). However, the desired level of >150 mcg/l was not achieved. Treatment with KI in the period of lactation within 2 months after delivery resulted in median urinary iodine excretion of = >100 mcg/l in 10.5% of the women in group 1. None of the patients in group 2 showed the required iodine concentration in the urine. It means that the minimal daily prophylactic dose of iodine for pregnant and lactating women should be 300 mg.

[Malignant insulinoma]

According to official statistics, malignant insulinomas account for a small fraction of gastroenteropathic endocrine neoplasms, the majority of insulinomas being essentially benign tumours. This paper reports a clinical case of malignant insulin-producing neuroendocrine tumour of the pancreas tail in a 28 year-old woman. She had multiple liver metastases and organic hyperinsulinism. Results of comprehensive examination of the patient at the Endocrinological Research Centre including laboratory diagnostic data and their evaluation are presented. Her surgical treatment was accomplished in N.N. Burdenko Facultative Surgery Clinic, I.M. Sechenov Moscow Medical Academy. Treatment strategy in the post-operative period and follow-up observations are described.