[Functional hypercortisolism in mental disorder - association with psychopathological manifestations and course of the disease]

The article presents a case of a long-term mental disorder in a 35-year-old woman with a persistent laboratory-confirmed increase in cortisol levels, without clinical manifestations of hypercortisolism. The first signs of mental illness appeared at the age of 14; over the past 8 years, the disease has been continuous and manifests itself in the form of a predominantly depressive state with increasing severity and complication of symptoms. Throughout all the years of the disease, active psychopharmacotherapy was carried out, combinations of antidepressants with antipsychotics and mood stabilizers were used, but no pronounced effect was achieved. Inpatient treatment in the clinic of the Mental Health Research Center for 5 months using several methods of enhancing antidepressant therapy had a good therapeutic effect and made it possible to achieve complete remission of the disease. There was a normalization of laboratory parameters of cortisol along with a decrease in the severity of pathopsychological symptoms, which indicates the genesis of hypercortisolism secondary to mental illness and its functional nature. It is assumed that hypercortisolism in this patient contributed to the formation of atypical clinical symptoms and resistance to antidepressant therapy. The discussion substantiates the need to consult a psychiatrist in case of persistent hypercortisolism in the absence of clinical manifestations of Cushing's syndrome. The detection of persistent hypercortisolism in patients with depression determines the advisability of active therapy using several tactics to enhance the effect of antidepressants.

[Mental disorders in type 2 diabetes]

OBJECTIVE

To assess the prevalence of mental disorders in patients with type 2 diabetes mellitus (DM2) and their relationship with laboratory findings, somatic comorbidities and psychosocial consequences.

MATERIAL AND METHODS

In the frames of the INTERPRET-DD multicenter 200 T2DM patients from primary care (47 men and 153 women) from the Russian sample were studied. The psychometric assessment included MINI-6, HAMD-17, PHQ-9, PAID, WHO-5.

RESULTS

One hundred and seventeen patients (58.5%) have mental disorders. Current mental disorders were diagnosed in 93 (46.5%) of patients. Depression (depressive episode, recurrent depressive disorder, bipolar affective disorder type II) was identified in 34 (17.0%), dysthymia in 26 (13.0%), and anxiety spectrum disorders in 39 (19.5%). In about half of the cases, anxiety disorders were combined with depression. The most severe problems were observed in the patients with depression and dysthymia. Patients with social phobia had significantly higher levels of glycated hemoglobin compared to patients without mental disorders. The significant decrease of systolic arterial pressure and body mass index was observed in patients with agoraphobia compared to patients without mental disorders. In addition, there was an increased prevalence of chronic ischemic heart disease in recurrent depression, dysthymia and generalized anxiety disorder, higher prevalence of neuropathy in depressive episode and recurrent depression and nephropathy in panic disorder.

CONCLUSION

Depressive and anxiety disorders, as well as severe psychosocial problems, are consistently associated with T2DM. At the same time, concomitant somatic disorders and complications of DM2 are not just by chance comorbid to various forms of mental disorders, which allows for a new look at the problem of comorbidity/multimorbidity in T2DM.

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition

Dear Colleagues! We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. In сurrent edition of the Standards: New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given. Added a snippet that describes the continuous glucose monitoring. Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism. Proposes more stringent target levels of blood pressure. It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion. In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages. Recommendations for psychosocial support are added. The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated. Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added. For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums. These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM. On behalf of the Working Group

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V., Mayorov A.Yu. 9th edition

Dear Colleagues! We are glad to present the 9th Edition (revised) of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2018, 2019), American Association of Clinical Endocrinologists (AACE, 2019), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014, 2018) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EXAMINE, ELIXA, SUSTAIN, DEVOTE, EMPA-REG OUTCOME, CANVAS, DECLARE, CARMELINA, REWIND, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 463 million patients by the end of 2019. According to the current estimation by the International Diabetes Federation, 578 million patients will be suffering from diabetes mellitus by by 2030 and 700 million by 2045. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4 584 575 patients with DM in this country by the end of 2018 (3,1% of population) with 92% (4 238 503) Type 2 DM, 6% (256 202) Type 1 DM and 2% (89 870) other types of DM, including 8 006 women with gestational DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) con- firmed that only 54% of Type 2 DM are diagnosed. So real number of patients with DM in Russia is 9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. In сurrent edition of the Standards: New goals of glycemic control for the elderly, based on the presence of functional dependence, as well as for pregnant women, children and adolescents, are given. Added a snippet that describes the continuous glucose monitoring. Only low-density lipoprotein cholesterol level is used as a target for lipid metabolism. Proposes more stringent target levels of blood pressure. It also features updated guidelines on stratification of treatment in newly diagnosed Type 2 diabetes: the excess of the initial level of HbA1c over the target level was used as a criterion. In the recommendations for the personalization of the choice of antidiabetic agents, it is taken into account that in certain clinical situations (the presence of atherosclerotic cardiovascular diseases and their risk factors, chronic heart failure, chronic kidney disease, obesity, the risk of hypoglycemia) certain classes of hypoglycemic agents (or individual drugs) have proven advantages. Recommendations for psychosocial support are added. The position of metabolic surgery as a method of treatment of DM with morbid obesity is updated. Recommendations for diagnostic and treatment of hypogonadism syndrome in men with DM are added. For the first time, evidence levels of confidence and credibility levels of recommendations for diagnostic, therapeutic, rehabilitative and preventive interventions based on a systematic review of the literature are given in accordance with the recommendations of the Center for Healthcare Quality Assessment and Control of the Ministry of Health of the Russian Federation. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discus- sions held at national meetings and forums. These guidelines are intended for endocrinologists, primary care physicians and other medical professionals involved in the treatment of DM. On behalf of the Working Group

Prevalence and correlates of depressive disorders in people with Type 2 diabetes: results from the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study, a collaborative study carried out in 14 countries

AIMS

To assess the prevalence and management of depressive disorders in people with Type 2 diabetes in different countries.

METHODS

People with diabetes aged 18-65 years and treated in outpatient settings were recruited in 14 countries and underwent a psychiatric interview. Participants completed the Patient Health Questionnaire and the Problem Areas in Diabetes scale. Demographic and medical record data were collected.

RESULTS

A total of 2783 people with Type 2 diabetes (45.3% men, mean duration of diabetes 8.8 years) participated. Overall, 10.6% were diagnosed with current major depressive disorder and 17.0% reported moderate to severe levels of depressive symptomatology (Patient Health Questionnaire scores >9). Multivariable analyses showed that, after controlling for country, current major depressive disorder was significantly associated with gender (women) (P<0.0001), a lower level of education (P<0.05), doing less exercise (P<0.01), higher levels of diabetes distress (P<0.0001) and a previous diagnosis of major depressive disorder (P<0.0001). The proportion of those with either current major depressive disorder or moderate to severe levels of depressive symptomatology who had a diagnosis or any treatment for their depression recorded in their medical records was extremely low and non-existent in many countries (0-29.6%).

CONCLUSIONS

Our international study, the largest of this type ever undertaken, shows that people with diabetes frequently have depressive disorders and also significant levels of depressive symptoms. Our findings indicate that the identification and appropriate care for psychological and psychiatric problems is not the norm and suggest a lack of the comprehensive approach to diabetes management that is needed to improve clinical outcomes.

Russian national clinical recommendations for morbid obesity treatment in adults. 3rd revision (Morbid obesity treatment in adults)

The presented paper is a third revision of the clinical recommendations for the treatment of morbid obesity in adults. Morbid obesity is a condition with body mass index (BMI) 40 kg / m2 or a BMI 35 kg / m2 in the presence of serious complications associated with obesity. The recommendations provide data on the prevalence of obesity, its etiology and pathogenesis, as well as on associated complications. The necessary methods for laboratory and instrumental diagnosis of obesity are described in detail. In this revision of the recommendations, the staging of prescribing conservative and surgical methods for the treatment of obesity are determined. For the first time, a group of patients with obesity and type 2 diabetes mellitus is selected, in whom metabolic surgery allows a long-term improvement in the control of glycemia or remission of diabetes mellitus.

Standards of specialized diabetes care. Edited by Dedov II, Shestakova MV, Mayorov AY. 8th edition

Dear Colleagues! We are glad to present the8th Editionof Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2012, 2017), American Association of Clinical Endocrinologists (AACE, 2017), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EMPA-REG OUTCOME, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 415 million patients by the end of 2015. According to the current estimation by the International Diabetes Federation, 642 million patients will be suffering from DM by 2040. These observations resulted in the UN Resolution on Diabetes 61/225 passed on 20.12.2006, and in 2011 - UN Political Declaration, addressed to national health systems, calling for the establishment of multidisciplinary strategy in the prevention and control of non-communicable diseases, where special attention is drawn to the problem of diabetes as one of the leading causes of disability and mortality. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4.35 million patients with DM in this country by the end of 2016 (3% of population) with 92% (4 million) Type 2 DM, 6% (255 th) Type 1 DM and 2% (75 th) other types of DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) confirmed that only 50% of Type 2 DM are diagnosed. So real prevalence of patients with DM in Russia is no less than 8-9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. Current edition of the Standards emphasizes the patient-oriented approach in making decisions on therapeutic goals, such as levels of glycaemia and blood pressure. It also features updated guidelines on the management of Type 2 DM and its vascular complications, added information about bariatric surgery as a method of treatment of DM with morbide obesity. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discussions held at national meetings and forums. These guidelines are intended for endocrinologists and diabetologists, primary care physicians, cardiologists and other medical professionals involved in prevention and treatment of DM. On behalf of the Working Group

[Hyperprolactinemia associated with neuroleptic treatment: clinical characteristics and an impact on sexual function]

AIM

To study clinical characteristics of antipsychotic-induced hyperprolactinemia (AIH) and an impact of AIH on sexual function in patients with mental disorders treated with neuroleptics for a long time.

MATERIAL AND METHODS

A cross-sectional study of 244 consecutive psychiatric in-patients (F/M=140/104) with mental disorders currently taking antipsychotics was carried out. The patients were screened for serum prolactin, sex hormones and gonadotropin levels. The UKU Side effects rating scale (UKU) was used to assess side-effects. For assessment of sexual dysfunction, the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ) was administered.

RESULTS AND CONCLUSION

Asymptomatic AIH was found in 16% of females and in 37% of males. AIH caused menstrual disorders (oligomenorrhea and amenorrhea), galactorrhea in females. AIH was associated with libido decrease and life quality impairment due to sexual dysfunctions in patients of both genders. AIH was associated with orgasm delay and vaginal dryness during sexual intercourse in females. In men, AIH was associated with erectile dysfunction. In contrast to pituitary tumor and idiopathic hyperprolactinemia, there was no association between AIH and weight gain and/or obesity, and hypogonadism in patients of both genders.

Prevalence and Prognostic Value of Depression and Anxiety in Patients with Diabetic Foot Ulcers and Possibilities of their Treatment

BACKGROUND

Depression and anxiety can potentially influence treatment results of diabetic complications.

OBJECTIVE

Of our study was to explore: (1) prevalence of these disorders in patients with diabetic foot ulcers (DFU); (2) possible risk factors of depression and anxiety; (3) possible links between ulcer treatment results and depression/anxiety status.

METHODS

285 outpatients with diabetes and foot or leg ulcers were tested for depression and anxiety with self-report scales: CES-D and the anxiety subscale from HADS. Ulcer treatment results, incidence of new ulcers and number of hospital admissions were assessed after 1.5 years of follow-up.

RESULTS

Depression was detected in 110 patients (39%), anxiety in 103 (36%). Females had depression and anxiety more often than males (48% and 46% vs. 27% and 25% respectively). A combined score based on diabetes duration, insulin treatment, history of myocardial infarction, history of foot ulcers and recent foot surgery was higher in patients with than without depression (3.0 vs. 2.0, p=0.02). Every of these or other potential risk factors alone was not associated with depression or anxiety. Patients with depression did not demonstrate poorer prognosis except higher mortality in subgroup of severely depressed patients without ulcer history. For anxiety we got similar results as its presence strongly correlated with depression.

CONCLUSION

The overall prevalence of depression and anxiety in DFU patients is compatible with other diabetic populations. Various parameters of ulcer severity and duration did not influence the probability of depression and anxiety occurrence. Depression in general was not associated with poorer ulcer treatment results.

[Mental disorders in patients with acromegaly]

AIM

To study mental disorders in acromegaly due to somatotropinoma.

MATERIAL AND METHODS

The study included 115 consecutively recruited patients with acromegaly (95 female and 20 male, aged from 21 to 78 years). Acromegaly was diagnosed by endocrinologists according to current guidelines based on clinical, laboratory data and brain MRI. All patients underwent a clinical psychiatric interview based on ICD-10 criteria. The Mini-Mental State Examination scale and Hypomania-Checklist (HCL-32) were used.

RESULTS

Mental disorders were diagnosed in 79.1% of patients. Organic spectrum disorders were found in 46.1%, bipolar spectrum disorders in 35.7%, schizophrenia spectrum disorders in 4.3%. The patients with bipolar spectrum disorders had significantly lower serum insulin-like growth factor 1 (IGF-1) levels compared to patients with organic spectrum disorders (p=0.01). The presence of organic spectrum disorders was associated with older age and number of somatic comorbidities (р=0.0001 and 0.001).

CONCLUSION

The prevalence of bipolar, organic and schizophrenia spectrum disorders in patients with acromegaly exceeds that in the general population. Significantly lower IGF-1 levels in acromegalic patients with bipolar disorders, compared to those with organic disorders, can have some implications to their pathogenesis.

The INTERPRET-DD study of diabetes and depression: a protocol

AIM

People with diabetes are at an increased risk of developing depression and other psychological disorders. However, little is known about the prevalence, correlates or care pathways in countries other than the UK and the USA. A new study, the International Prevalence and Treatment of Diabetes and Depression Study (INTERPRET-DD) aims to address this dearth of knowledge and identify optimal pathways to care across the globe.

METHOD

INTERPRET-DD is a 2-year longitudinal study, taking place in 16 countries' diabetes outpatients' facilities, investigating the recognition and management of depressive disorders in people with Type 2 diabetes. Clinical interviews are used to diagnose depression, with clinical and other data obtained from medical records and through patient interviews. Pathways to care and the impact of treatment for previously unrecognized (undocumented) depression on clinical outcomes and emotional well-being are being investigated.

RESULTS

Initial evidence indicates that a range of pathways to care exist, with few of them based on available recommendations for treatment. Pilot data indicates that the instruments we are using to measure both the symptoms and clinical diagnosis of depression are acceptable in our study population and easy to use.

CONCLUSIONS

Our study will increase the understanding of the impact of comorbid diabetes and depression and identify the most appropriate (country-specific) pathways via which patients receive their care. It addresses an important public health problem and leads to recommendations for best practice relevant to the different participating centres with regard to the identification and treatment of people with comorbid diabetes and depression.

[Analysis of a continuous 24-hour glycemic curve by the symmetrization method]

The study included 18 patients (10 females and 8 males) with a not less than 2 year-history of type 1 diabetes (T1D), who had received insulin therapy since its diagnosis was established. The patients ' mean age was 32.9± 13.0 years; the mean duration of TID was 15.1+11.5 years; the mean daily dose of insulin was 40.1+16.0 units; the mean level of glycosylated hemoglobin (HbAJ was 9.4±2.1% (the normal value 4.4-4.9%). The glycemic curve symmetrization method proposed for statistical analysis of glycemic self-control is also quite suitable for the statistical monitoring of a continuous daily glycemic curve. The high and low glycemic indices calculated from the symmetrized glycemic data correlate well with the level of HbAk and with the duration of hypoglycemia and hyperglycemia and hence they may be used as additional criteria for a risk of diabetes complications. The criteria, calculated from the symmetrized data of glycemia for the risk of hyper- and hypoglycemia, adequately reflect the behavior of a continuous glycemic curve and may be used as integral indices of the efficiency of glucose-reducing therapy in clinical practice.

[Antihypertensive treatment compliance and obstacles to its improvement. Results of Russian program ARGUS-2]

AIM

To study barriers made by the patients for adequate treatment of arterial hypertension.

MATERIAL AND METHODS

The ARGUS-2 trial was made in 15 centers of 13 cities of Russia. Anonymous questionnaire survey covered 1298 patients (796 outpatients and 502 inpatients). The patients answered the following questions: 1) what are basic problems of life with hypertension; 2) compliance with intake of antihypertensive drugs; 3) causes of missed intakes of the drugs; 4) opposition to intake of drugs by the patients. Questioning procedure was preset by the trial protocol.

RESULTS

Only 37.4% (38.9% outpatients, 34.6% inpatients) were the treatment adopters. Drug intake was missed most frequently because offorgetting. The problems of life with hypertension were differently interpreted by patients and physicians: for the latter main problems were financial and routine while AH complications were on the 6-7 place. The latter were of primary importance for the patients while financial problems took place 4-6 Barriers to regular intake for the patients were poor self-control and unawareness about side effects of the drugs.

CONCLUSION

Complience of the patient can be improved only by complex approach: improvement of education, higher motivation, active involvement of patients into the treatment process, better contacts between the physician and the patient.

[Problems of a physician-patient interaction and control of arterial hypertension in Russia. Main results of scientific-practical program ARGUS-2]

OBJECTIVE

To study the problems of physician-patient cooperation, patient- and physician related barrieres to target blood pressure (BP) achievement and to demonstrate improvement of BP control with indapamide SR 1.5 mg, when given to patients remaining uncontrolled while receiving antihypertensive therapy without thiazide diuretics (TD).

METHODS

The trial Improvement of Arterial Hypertension Control in High-Risk Hypertensive Patients (ARGUS-2) run in 15 Russian centres during the year 2006. Retrospective analysis of medical notes of 684 outpatients and 575 inpatients with arterial hypertension. Validated questionnaires were used for interview of 373 physicians and 1298 patients. The study of Arifon retard efficacy was carried out in 1438 outpatients with difficult-to-control hypertension.

RESULTS

BP was above the goal level in 97.1% pts at the first analyzed visit to an outpatient department. Antihypertensive therapy was unchanged in 20.5% cases, the drug dose was increased in 46,6%, additional medication was administered in 36,8%. In 30.8% pts antihypertensive agent was substituted by another class drug. At the last analyzed visit target BP was found in 24.4% pts. BP control was poorer in pts with BP goal <130/80 mmHg (20.1%) than in those with higher target BP (25.9%). Achievement of BP goal was associated with combination therapy, higher rate of TD administration and with more frequent visits to physician. During hospitalization target BP <140/<90 mmHg was achieved in 87.1%,<130/<80 mmHg in. 76.2%. Arifon retard administration resulted in target BO achievement in 84.5% patients. Physicians percept low adherence to antihypertensive treatment, lack of patients knowledge about risk related to arterial hypertension, economical problems as main barriers to improvement of arterial hypertension management. Patients considered economical problems related to antihypertensive treatment more much less important than physicians did.

CONCLUSION

The study results suggest the importance of therapeutic inertia overcome to improve arterial hypertension management in Russia. Low rate of multiple combination therapy and TD prescription are important features of therapeutic inertia. Polar perception of problems related to arterial hypertension by physicians and patients should be considered as influencing factors for educational programs development.

[How physicians and patients look at the problem of obesity]

AIM

To elicit attitude of physicians and population to the problem of obesity; to assess awareness and diagnostic and therapeutic tool.

MATERIAL AND METHODS

A questionnaire survey was performed among 384 endocrinologists and 54 other medical professional in 13 cities of Russia. 1405 randomly selected citizens of Moscow (males and females) aged 18-64 years were interviewed according to the standard questionnaire on the telephone.

THE RESULTS

Opinion of the physicians. Endocrinologists think that the key factors of weight gain are the following: overeating (81%), hypodynamia (53%), heredity (36%), endocrine pathology (20%), diet rich in fat (18%). Body weight is assessed on the basis of BWI (80%), weight-height tables (38%), Brock's formula (25%), waist and hip circumferences (21%). Endocrinologists believe that obesity should be treated to improve wellbeing (75%), concomitant syndromes (53%), appearance (4%). 92% of endocrinologists recommend a low-calory diet, 82%--physical exercise, 15%--medication, 6%--food additives. Potential patients. 1/3 of city population have overweight. 1/4 of them want to lose weight. Women want to lose weight three times more frequently than men. The proportion of men and women wanting to lose weight is higher at the age group of 40-49 years. Obese subjects more frequently than subjects with normal weight want to lose weight without keeping diet (53 vs 39%) or extra physical activity (38% vs 27%). Women more frequently use methods of losing weight (both registered and unregistered).

CONCLUSION

Physicians underestimate the role of obesity in genesis of concomitant diseases, the role of high-calory diets in development of obesity. Most of potential patients have an inadequate attitude to the necessity and feasibility of weight loss, are unrealistic as to methods of losing weight and effectiveness of such methods.

[Analysis of the quality of primary therapeutic-preventive care rendered to patients with type I diabetes mellitus]

A prospective follow-up of a random sample of patients with insulin-dependent diabetes mellitus revealed a marked decompensation of carbohydrate metabolism in 98% of the examinees, a high incidence of diabetic ketoacidosis, a long duration of temporary invalidity, and poor adherence of patients to medical recommendations. Assessment of primary health care rendered to patients with type I diabetes at district outpatient clinics of Moscow demonstrated its poor efficacy and a necessity to improve the level of specialized diabetologic care.

[Effectiveness of an intensive treatment and training program for patients with type I diabetes mellitus]

The authors analyze the results of comprehensive, prospective, controlled investigation of the program for intensive care and training of 121 patients with insulin-dependent diabetes mellitus (IDDM). The basic principles of the program are training on a team's basis, intensive insulin therapy, auto-monitoring of metabolism, and liberal diet. The results demonstrate that glycemia level approaching the normal may be attained and maintained in the majority of patients without increasing the risk of grave hypoglycemia, cases with severe diabetic ketoacidosis may be eliminated, and periods of temporary invalidity of patients reduced by 7-10 times. The selected training program was equally effective for patients of various age groups and levels of education, as well as for patients with "labile" diabetes. Results of treatment did not depend on the type of insulin preparations used. The authors come to a conclusion on a higher efficacy of new strategy of IDDM treatment in comparison with the traditional approaches.

[Age-related features of neurohumoral regulation of somatotropic hormone secretion]

Experiments with primary cultures demonstrated a stimulating effect of TRF on somatotropic hormone (STH) secretion by hypophyseocytes of neonatal but not adult rats and a reduced reactivity of neonatal somatotrophs to the inhibitory effect of somatostatin during short-term incubation. No noticeable serotonin effect on STH release from hypophyseal cells of animals of various ages was observed. During prolonged (24 h) incubation a weak inhibitory effect of bromocriptine and melatonin on STH secretion by pituitary cells of neonatal but not adult rats was observed. These results permit us propose a similarity of the functional characteristics of neonatal pituitary somatotrophs to somatomammotroph properties.

Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow--blood glucose versus urine glucose self-monitoring

In a prospective controlled trial the effects of a 5-day in-patient treatment and teaching programme for Type 1 (insulin-dependent) diabetes mellitus on metabolic control and health care costs were studied in Moscow. Two different intervention programmes were compared, one based upon urine glucose self-monitoring (UGSM, n = 61) and one using blood glucose self-monitoring (BGSM, n = 60). Follow-up was 2 years. A control group (n = 60) continued the standard treatment of the Moscow diabetes centre and was followed-up for 1 year. Costs and benefits with respect to hospitalizations and lost productivity (according to average wage) were measured in November 1992 rubles (Rb.), with respect to imported drugs and test strips in 1992 German marks (DM). In the intervention groups there were significant decreases of HbA1 values [UGSM: 12.5% before, 9.4% after 1 year, 9.2% after 2 years (p < 0.0001); BGSM: 12.6% before, 9.3% after 1 year, 9.2% after 2 years (p < 0.0001) compared to no change in the control group (12.2% before, 12.3% after 1 year)], and of the frequency of ketoacidosis. The frequency of severe hypoglycaemia was comparable between the UGSM (10 cases during 2 years), BGSM (10 cases during 2 years), and the control group (8 cases during 1 year).(ABSTRACT TRUNCATED AT 250 WORDS)

[Relationship between glucose utilization by tissues and residual insulin secretion and their role in the genesis of hyperglycemia in type I diabetes mellitus]

Altogether 67 patients aged 16 to 50 suffering from insulin dependent diabetes mellitus (IDDM) of various duration were investigated to study the effect of peripheral sensitivity to insulin on genesis to hyperglycemia in type I diabetes mellitus. Residual beta-cell insulin secretory function was assessed by the level of C-peptide in a standard food test, and the rate of glucose utilization by tissues was studied by the clamp-method under the conditions of normoglycemia. The results obtained indicate the role of a decrease in peripheral sensitivity to insulin in genesis of hyperglycemia in diabetes mellitus, type I, and the presence of reciprocal interactions between glucose utilization and insulin secretion in IDDM patients and in controls.

Effect of training on the performance of blood glucose monitoring using a reagent strip (Glucoprofil)

A relatively simple, new test-strip for blood-glucose monitoring, the Glucoprofil strip with a reaction-zone of film-foil, was evaluated by testing 100 different blood glucose concentrations between 2.1 and 29.7 mmol/l. The results were obtained visually before and after training to read the color changes of the strip according to the scale on the strip-container. Plasma glucose measurements with the Beckman Glucose-Analyzer were used for reference. The results show that the Glucoprofil-strip readings correlated well with the reference method (r = 0.97), thorough training provided. The mean deviation of the strip results was less than 1 mmol/l. Similar results were obtained using another blood glucose strip, the Haemoglukotest 20-800 R. Our study indicates that the performance of the Glucoprofil strip is satisfactory, and hence the strip may be useful for clinical purposes. Consistent with previous reports we could demonstrate that training improved the reading results of the Glucoprofil strip.

Diabetes education in the USSR: how to begin?

To determine patients' attitudes towards diabetes education in the Soviet Union, a questionnaire was distributed throughout the country. From 10,000 completed forms, returned from all regions of the USSR, 2000 were analysed in detail. Responders represented all age and social groups, but patients with shorter duration of diabetes, and women, responded more readily. More than 41% of patients were unaware of the type of diabetes they had, the actual proportions of Type 1 and Type 2 diabetes among respondents being 31 and 63%. Rates of chronic complications derived from patients' answers suggest a high rate of underestimation by local physicians. Only 17% of Type 1 and 8% of Type 2 diabetic patients believed that they knew enough about diabetes, and 99.9% of all respondents wanted to learn more about their disease. Independently of the type of diabetes and educational level, patients would accept the information on diabetes from periodicals (63-68%), television (48-63%), booklets for patients (29-31%), as well as attending diabetes courses or classes (30-38%). They expressed preference for teaching conducted by physicians (74-85%) rather than nurses (1-4%). The main areas of interest for Type 1 diabetic patients were technical devices, (artificial pancreas and insulin pumps (85%] and late diabetic complications (78%), and for patients with Type 2 diabetes late complications (84%) and diet (72%). Some respondents (20-25%) expected the use of herbs and other 'non-traditional' methods to be effective in treatment and curing of diabetes. The least requested topics were acute complications (18-34%) and metabolic self-monitoring (0.025%).(ABSTRACT TRUNCATED AT 250 WORDS)

[The insulin and proinsulin levels in patients with newly detected diabetes mellitus]

Total immunoreactive insulin (IRI), proinsulin-like component, IRI, C-peptide and glucagon were determined in patients with newly detected diabetes mellitus and in healthy subjects on an empty stomach and after food testing. The results obtained have shown that a study of the serum total IRI composition combined with C-peptide determination during food testing can be used as a diagnostic test to define a type of diabetes mellitus.

[Use of the monopeak insulin drugs "insulrap" and "insulong" in the treatment of type I diabetes mellitus]

A study was made of the effectiveness of the use of new monopeak insulin drugs of short-term and prolonged action in therapy of 30 patients with type 1 diabetes mellitus. The effect of the drugs was estimated during a follow-up (1-6 mos.) by the parameters of carbohydrate metabolism and the time course of serum insulin binding capacity as well as by change in a dose of insulin as compared to that of the common Soviet drugs of the insulin-zink-suspension (IZS) group and monopeak drugs of the Long group. The drugs under study were shown to be no inferior to the monopeak drugs of the Long group and in some cases superior to the drugs of the IZS group. A significant decrease in the titer of antibodies to insulin against a background of therapy was unnoticed. Positive and negative qualities of both drugs (Insulrap and Insulong) were discussed.

[Combined use of automatic systems for treating patients with type 1 diabetes mellitus]

The efficacy of the combined consecutive use of the apparatus "Artificial Pancreas" (Biostator) and portable dosing apparatuses of insulin (Microjet) was investigated in 21 patients with type I diabetes mellitus in order to work out a method for glycemia correction. Preliminary results of the use of Biostator provided an opportunity for preparing an adequate scheme of insulin administration using microdosing apparatuses. The method made it possible to reduce the time for achieving compensation of the disease and attaining partial remission in patients with newly diagnosed type I diabetes mellitus.