Draft resolution of the expert council of the сhief specialists of the North-West Federal District on the identification of prediabetes and the prevention of type 2 diabetes mellitus and related diseases of cardiovascular system, liver, musculoskeletal system

Considering high prevalence of prediabetes, exceeding the incidence of type 2 diabetes mellitus, clear algorithms for identifying and managing patients with this pathology is the most important task for doctors of various specialties — therapeutists, cardiologists, general practitioners. The preventive measures are more efficient when started at the stage of prediabetes rather than when type 2 diabetes mellitus has been developed. They help to prevent or delay the development of type 2 diabetes mellitus, its micro- and macrovascular complications, cardiovascular diseases, pathology of muscular-skeletal system and liver. All these measures should be implemented at the stage of primary health care. The resolution presents an algorithm of verifying and management of prediabetes and type 2 diabetes mellitus.

Insulinoma: diagnostic features and treatment management

Background. Insulinoma is the most common functional pancreatic neuroendocrine tumor originating from β-cells, with unregulated insulin production and rarely associated with MEN-I syndrome. Diagnosis and treatment of insulinoma are a challenge in the practice of endocrinologist. Aim. To determine on the basis of retrospective analysis the optimal approaches to the management of patients with organic hyperinsulinism. Material and methods. Medical records of 72 patients admitted with suspected organic hyperinsulinism had been screened and medical histories of patients with a confirmed diagnosis of organic hyperinsulinism were included into the analysis. Anamnesis, results of objective, laboratory and instrumental examinations, methods and results of the treatment were analyzed. Results. The diagnosis of insulinoma was confirmed in thirty two cases. Hypoglycemia was achieved within the first 48 hours after the start of the 72-hour fasting test in 100% of cases. Study results showed that in 50% of cases the size of the pancreatic neoplasm was more than 1.4 cm. Inverse correlation between tumor size and plasma glucose concentration at the time of hypoglycemia was found (r=–0.45; р=0.02). Surgical treatment was carried out in thirty out of 32 patients. Surgical enucleation of insulinoma was performed in 12 (40%) cases, distal pancreatectomy — in 18 (60%). Insulinoma was confirmed in 27 cases, while in three patients diagnosis of non-insulinoma pancreatogenous hypoglycemia («nesidioblastosis») was established according to histological findings. Positive clinical result was achieved after all surgeries. In postoperative period patients were discharged within 11—30 days. Patients without post-operative complications were discharged 13.0±1.4 days after surgery. Twelve (40%) patients developed post-operative complications. The duration of hospital stay in these cases was significantly longer 20.1±1.9 (р<0,01). Conclusion. Obtained data confirmed that comprehensive approach including 72-hours fasting test, use of modern imaging techniques and application of high-tech treatment methods, is crucial for successful diagnosis and treatment of insulinoma.

[Highly selective sodium-glucose co-transporter type 2 inhibitor empagliflozin as means of brain protection in conditions of chronic brain dyscirculation]

BACKGROUND

Chronic brain dyscirculation is one of the frequent type 2 diabetes mellitus (DM) complications and leads to patients' disability. Sodium-glucose co-transporter type 2 inhibitors (SGLT-2i) have been proven to have advantages for cardiovascular system, but their effect on the central nervous system (CNS) has not been studied enough.

AIM

To study empagliflozin effect on CNS damage functional and laboratory parameters in patients with type 2 DM and, under experimental conditions, to investigate the mechanisms of the drug neurotropic effect.

MATERIALS AND METHODS

The clinical part of the study included patients with type 2 DM on metformin monotherapy (n=39). Patients with a target glycated hemoglobin level formed the "MET" group (n=19), in patients with a non-target glycated hemoglobin level empagliflozin was co-administered for the following 6 months (the "MET+EMPA" group, n=20). Healthy volunteers comprised the control group (n=16). The cognitive status and neuron-specific enolase (NSE) and neurofilament light chains (NLC) concentration were studied. DM was modeled in rats, thereafter the rats were treated with empagliflozin for 8 weeks. Microglia activation was assessed using anti-Iba-1 antibodies and morphological changes in neurons when stained by the Nissl method.

RESULTS

Both in the "MET+EMPA" and the "MET" groups cognitive deficits were observed, according to the Montreal Cognitive Assessment (MOCA) (24.0 (23.0; 27.0) and 25.0 (21.0; 27.0) points) and the Mini-Mental State Examination (MMSE) (23.75 (23.0; 27.0) and 25.0 (21.0; 27.0) points). Empagliflozin therapy led to the cognitive status normalization after 6 months (26.5 (24.0; 27.0) points according to the MOCA scale and 27.5 (24.0; 28.0) points according to the MMSE). Initially, all patients had a significant increase of NSE (3.60 (2.66; 3.76) ng/ml in the "MET" group, 3.22 (2.94; 3.54) ng/ml in the "MET+EMPA» group, 2.72 (2.13; 2.72) ng/ml in the «Control» group) and NLC (4.50 (3.31; 5.56) ng/ml in the «MET» group, 5, 25 (3.75; 6.25) ng/ml in the «MET+EMPA» group comparing with 3.50 (2.25; 3.50) ng/ml in the «Control» group). Empagliflozin therapy led to a significant decrease in NLC already after 3 months (3.80 (3.25; 3.87) ng/ml), without significant influence on the NSE level. In the experiment, DM was characterized by an increased number of activated microgliocytes and destructured neurons and a decreased number of neurons with a normal structure. Empagliflozin therapy was accompanied by a decrease in the number of immunopositive microgliocytes in the CA1 zone of the hippocampus and an increase in the number of structured neurons.

CONCLUSION

Type 2 diabetes mellitus is characterized by functional and biochemical changes in the central nervous system even under satisfactory glycemic control. Therapy with empagliflozin has a neuroprotective effect, manifested in an improvement in cognitive status and a decrease in NLC level. Empagliflozin reduces neuronal damage and abnormal microglial activation.

Pharmacological correction of experimentally induced osteoporosis complicated by type 2 diabetes mellitus

BACKGROUND: Osteoporosis remains one of the most important medical problems worldwide with significant economic consequences. The development of new drugs based on unique biologically active compounds can contribute significantly to osteoporosis management. AIM: To evaluate the osteogenesis processes by evaluating bone-remodeling markers in the blood serum during the treatment of experimental osteoporosis complicated by type 2 diabetes mellitus. MATERIALS AND METHODS: The study was performed on an experimental model of osteoporosis, followed by the induction of type 2 diabetes mellitus, using biochemical methods to analyze markers of osteoporosis in the blood serum. RESULTS: The results of the analysis of bone remodeling markers revealed that the antiosteoporotic activity of a composite preparation based on succinic acid salts is dependent on glucose metabolism disorders such as diabetes mellitus. The high efficacy of the new drug in monotherapy and combination with vitamin D3 in the activation of osteogenesis in experimental osteoporosis was balanced by impaired metabolic processes in type 2 diabetes mellitus. CONCLUSIONS: The results indicate the dependence of the pharmacological effectiveness of the antiosteoporosis agent on metabolic disorders, such as type 2 diabetes mellitus, in female rats with experimental osteoporosis.

Vitamin D status during the COVID-19 pandemic: the experience of Russia and Belarus

During the COVID-19 pandemic, a high prevalence of vitamin D deficiency and insufficiency remains. Thus, the studies carried out on the territory of the Russian Federation (RF) and the Republic of Belarus over the last 3 years have shown the prevalence of vitamin D deficiency and insufficiency in the population, regardless of the gender of examined persons, the geographic location and the season of the year. Taking into account the known immunomodulatory functions of serum 25(OH)D, the aim of this review was to assess the data that were accumulated in the world, Russia and Belarus and were concerned with a possible contribution of vitamin D deficiency to COVID-19 infection, course and prognosis, as well as with the role of cholecalciferol therapy in prevention and treatment of the disease. Most of the studies demonstrate a negative association between the serum 25(OH)D level and COVID-19 severity and/or mortality. Previously, it has been shown that the serum 25(OH)D level less than 11.4 ng/ml is associated with an increased risk of COVID-19 mortality. At the same time, the results of the studies using cholecalciferol therapy for COVID-19 prevention and treatment are conflicting. Intervention  studies in the Russian Federation and the Republic of Belarus are scanty; however, the available data indicate a possible  benefit of therapy, which allows it to be considered as an addition to the main methods of treating COVID-19.

Parathyroid gland disorders and cardiovascular disease

The review provides systematic information on the relation between pathology of parathyroid glands and cardiovascular disease (CVD). Recent studies have shown that actions of parathyroid hormone (PTH) and calcium affect the heart and vasculature through downstream actions of their receptors in the myocardium and endothelial cells, which lead to higher incidence of CVD among patients with parathyroid gland disorders (PGD). The mechanisms underlying this association also include insulin resistance and altered renin-angiotensinaldosterone axis among patients with primary hyperparathyroidism. However, low calcium and PTH level in hypoparathyroid patients are characterized by higher values of arterial stiffness, electrocardiogram abnormalities, vascular atherosclerosis and remodeling. These factors contribute to low quality of life among those patients. Knowledge of cardiovascular disease pathogenesis in patients with hyper- or hypoparathyroidism could help to improve quality of diagnostic and treatment and decrease the burden of cardiac risk factors. This review will be of interest to endocrinologists and cardiologists, and other specialists.

Fibroblast growth factor 21: a novel link in the development and treatment of metabolic disorders

In recent years, fibroblast growth factor 21 (FGF21) has garnered increasing attention as a metabolic regulator. It plays a role in the development of tissue insulin sensitivity, exerts beneficial effects on carbohydrate and lipid metabolism, and exhibits antihyperglycemic and antilipidemic properties. Elevated FGF21 levels have been observed in patients with type 2 diabetes, obesity, non-alcoholic fatty liver disease, and a range of other conditions. This may indicate either resistance to FGF21 or a compensatory response to metabolic stress. Evidence suggests that FGF21 can be considered both a marker of several metabolic disorders and a potential therapeutic agent for the treatment of significant societal health issues. Objective. The objective of this review is to summarize the data published to date in the literature, including meta-analyses, reviews, and original studies, focusing on the diagnostic and potential therapeutic role of FGF21 in metabolic disorders.

Evaluation of biosimilarity of RinGlar® (GEROPHARM LLC, Russia) and Lantus® (Sanofi-Aventis Deutschland GmbH, Germany) using the euglycemic hyperinsulinemic clamp technique in patients with type 1 diabetes: double-blind randomized clinical trial

Background: Prevention of the development of micro-and macrovascular complications in patients with diabetes melli-tus (DM) encouraged the search for insulin analogues that allow imitating, as close as possible, a normal physiological insulin secretion in healthy people. Biosimilars (bioanalogues of reference products) play an important role in the full provision with high-quality insulin medications throughout patients. The program of clinical trials of insulin bioanalogues includes pharmacology studies: pharmacokinetics (PK), pharmacodynamics (PD) and clinical safety research.

Aims: To test whether RinGlar® (GEROPHARM LLC, Russia) and Lantus® (Sanofi-Aventis Deutschland GmbH, Germany) have similar PK and PD profiles in a hyperinsulinemic euglycaemic clamp (HEC) setting in patients with type 1 diabetes mellitus. Permission of the Ministry of Health of the Russian Federation No. 150 of 03/03/2016.

Materials and methods: The study was conducted in 42 patients with type 1 diabetes aged 18 to 65 years. A doubleblind, randomized, crossover study of comparative PK and PD of drugs was chosen as a study design. The investigational products were injected after achieving a state of euglycemia before the HEC in a single dose of 0.6 U/kg subcutaneously into the subcutaneous fat of the anterior abdominal wall. During the study, regular blood sampling was performed, the amount of insulin glargine in the samples was determined by ELISA. The results are used to calculate the PK parameters and generate the concentration-time curves. The glucose infusion rate was corrected based on the measurement of glycemia. These data are used to calculate the PD parameters.

Results: RinGlar® and Lantus® interventions have comparable PK and PD profiles in HEC setting in patients with type 1 diabetes. This is confirmed by the similarity of the main PK/PD parameters, PK/PD curves, and comparable safety. The confidence intervals of the geometric mean ratio were 81.02% - 120.62% for the PK parameter AUCins0-T, and 85.43% - 115.64% for the PD-parameter AUCGIR0_T, which fall within the specified limits of 80% - 125% to establish comparability between drugs.

Conclusions: Results of the clinical trial demonstrate the biosimilarity of the products RinGlar® and Lantus®.

The efficacy of dopamine agonist therapy in a young man with a giant prolactinoma: case report

Prolactinomas are the most common of hormone secreting pituitary adenomas. Patients with prolactinomas generally have a benign prognosis. An algorithm is currently available for managing of this disease. Giant prolactinoma larger than 40 mm with severe invasive growth account for about 2—3% of the prolactin-secreting pituitary adenomas and evidence about management of such patients is limited. This case illustrates progress of a giant prolactin-secreting pituitary adenoma up to 70 mm in young male with a family history of prolactinomas in the absence of the adequate therapy for 8 years after initial diagnosis. After evaluation, it was decided to prescribe medical treatment. Cabergoline therapy started after evaluation appeared to be effective and had lead to significant decrease of serum prolactin level and shrinkage of pituitary adenoma. Described case emphasize the crucial role of identification of hyperprolactinemia among young patients on early stages of the disease. Our observation implies that treatment with dopamine agonists might be effective even in cases with giant prolactinomas.

The effect of vitamin D therapy on inflammatory markers in patients with type 2 diabetes mellitus and diabetic peripheral polyneuropathy

BACKGROUND: The pathogenesis of diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (T2DM) is multifactorial, and includes increased inflammation. In recent years, the effect of vitamin D therapy on improving the profile of inflammatory parameters has been actively studied. AIMS: The aim of this study was to assess inflammation markers before and after various doses of cholecalciferol therapy in T2DM with DPN. MATERIALS AND METHODS: Single-center open randomized study included T2DM patients with PDN. Sixty-seven patients were randomized into 2 groups. For 24 weeks Group I have been taking a dosage of cholecalciferol 5,000 IU/week, and Group II a dosage of 40,000 IU/week. At the baseline and in the end of the research there have been studied body mass index (BMI), glycated hemoglobin (HbA1c), 25-hydroxyvitamin D (25(OH)D), PTH, interleukin-1, -6, -10 (IL), C-reactive protein (CRP), tumor necrosis factor - (TNF). RESULTS: Sixty-two patients completed the study. Group I (n=31, F16), Group II (n=31, F15) were initially compared by age, sex, BMI and НbA1clevel. Vitamin D deficiency/insufficiency was detected in 78% of patients with T2DM. After 24 weeks of therapy with cholecalciferol in Group II there was a significant decrease in BMI, HbA1c, IL-6 levels and an increase in IL-10 levels while no changes were found in Group I. There has been established a correlation between the final level of 25(OH)D and IL-6 (r=-0.378, p=0.036), IL-10 (r=0.483, p=0.006), BMI (r=-0.388, p=0.031) and НbA1c(r=-0.388, p=0.031). CONCLUSION: The intake of cholecalciferol at a dosage of 40,000 IU/week for 24 weeks is associated with a decrease in BMI, improvement of glycemic control and pro-inflammatory markers profile in patients with T2DM with DPN. Study results showed that the normalization of serum 25(OH)D level can be one of the modifying factors for the development and progression of DPN in patients with T2DM.

Microglia Involvement into Acute and Chronic Brain Damage in Diabetic Rats: Impact of GLP-1RA and SGLT-2i

BACKGROUND

Acute and chronic brain damage in type 2 diabetes mellitus (DM) determines the need to investigate the neuroprotective potential of glucose-lowering drugs. The purpose was to directly compare the neuroprotective effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) with different duration of action and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) in type 2 diabetic rats with and without stroke.

METHODS

DM was modelled using high-fat diet and nicotinamide+streptozotocin protocol. The following groups (n = 15 each) were formed: DM without treatment, treatment with liraglutide, dulaglutide, canagliflozin as well as control group without DM and treatment. After 8 weeks, 10 rats from each group underwent middle cerebral artery occlusion. In the reperfusion period neurological deficit, neuroglial damage markers and brain necrosis were evaluated. Brain slices from the remaining 5 animals in each group were histologically examined for microglial activation and neuronal damage.

RESULTS

Brain damage was similar in "DM" and "Control" (17.53 [14.23; 26.58] and 15.87 [13.40; 22.68] % of total brain volume, respectively). All study drugs diminished damage volume comparing with "DM" and "Control" whereas the necrosis volume in "DM+Liraglutide" was smaller than in "DM+Canagliflozin" and did not significantly differ from "DM+Dulaglutide" (2.9 [1.83; 4.71], 6.17 [3.88; 8.88] and 4.57 [3.27; 7.90] %). The neurological deficit was more prominent in "DM" than in "Control", while all the drugs demonstrated similar positive effect. Neurofilament light chains (NLC) did not differ between "DM" and "Control". Dulaglutide and canagliflozin caused a marked decrease in NLC. Protein S100BB level was similar in "DM" and "Control". Liraglutide caused the largest S100BB decrease, while canagliflozin did not influence it. In chronic brain ischaemia, all drugs increased the number of normal neurons, but GLP-1RAs had a more pronounced effect. DM was accompanied by increased number of activated microglial cells in Cornu Ammonis (CA)1 hippocampal region. Both GLP-1RAs reduced the number of Iba-1-positive cells, with dulaglutide being more effective than liraglutide, whereas canagliflozin did not affect this parameter.

CONCLUSIONS

GLP-1RAs and SGLT-2i have neuroprotective properties against acute and chronic brain damage in diabetic rats, although the infarct-limiting effect of GLP-1RAs may be more pronounced. GLP-1RAs and SGLT-2i exert their protective effects by directly influencing neuronal survival, whereas GLP-1RAs also affect microglia.

Comparative study of the neuroprotective potential of semaglutide injectable preparations in experimental ischemic stroke

Introduction. Stroke remains one of the major causes of death in type diabetes mellitus (DM). Injectable form of glucagon-like peptide-1 receptor agonist semaglutide, Ozempic® decreases the stroke risk. In Russia there appeared a biosimilar Semavic® but its effects on the brain are not yet studied.

Aim. To compare neuroprotective properties of Semavic® and Ozempic® while used before ischemic stroke in rats without DM.

Materials and methods. The study was conducted in male Wistar rats that were divided into the following groups: “Control” (n = 10) – 0.9% NaCl, “MET” (n = 9) – metformin 200 mg/kg once daily per os, “Ozempic” (n = 10) – Ozempic® 0.012 mg/kg s.c. once daily, “Semavic” (n = 9) – Semavic® 0.012 mg/kg s.c. once daily. After 7 days ischemic stroke was modelled, after 48 hour of reperfusion neurological deficit and brain damage volume were evaluated. Glycemia was measured on the 3rd, 7th days as well as during and after ischemia.

Results. None of the study drugs caused hypoglycemia including in poststroke period. Neurological deficit in “MET” group did not differ from that in the “Control” (11.00 [6.50; 12.50] and 10.0 [6.25; 12.00] scores). Both semaglutide drugs caused comparable improvement in neurological status (14.00 [12.00; 18.00] and 14.00 [11.00; 18.00] scores in “Ozempic” and “Semavic” groups). Brain necrosis volume in “Control” group was 16.60 [13.40; 28.58] %. All the study drugs had infarct-limiting effect but brain damage volume in “Ozempic” (6.00 [4.32; 8.44] %) and “Semavic” (7.69 [2.99; 11.33] %) was smaller than in “MET” group (13.07 [8.67; 29.94] %). There were no differences between semaglutide drugs.

Conclusions. Biosimilar Semavic® and original Ozempic® demonstrate comparable neuroprotective effect while used in animals without DM prior to ischemic stroke modelling. This protective effect is not due to the drugs’ influence on glycemic profile.

Artificial intelligence for predicting mortality in hospitalized COVID-19 patients

BACKGROUND

The global demographic situation has been significantly impacted by the COVID-19 pandemic. The objective of this study was to develop a model that predicts the risk of COVID-associated mortality using clinical and laboratory data collected within 72 h of hospital admission.

MATERIALS AND METHODS

A total of 3024 subjects with PCR-confirmed COVID-19 were admitted to Almazov National Research Medical Center between May 2020 and August 2021. Among them, 6.25% (n = 189) of patients had a fatal outcome. Five machine learning models and the Boruta-SHAP feature selection method were utilized to assess the risk of mortality during COVID-19 hospitalization.

RESULTS

All methods demonstrated high efficacy, with ROC AUC (Receiver Operating Characteristic Area Under the Curve) values exceeding 80%. The selected Boruta-SHAP features, when incorporated into the random forest model, achieved an ROC AUC of 93.1% in the validation.

CONCLUSION

Throughout the study, close collaboration with healthcare professionals ensured that the developed tool met their practical needs. The success of our model validates the potential of machine learning techniques as decision support systems in clinical practice.

Bone remodeling in experimental diabetes mellitus and surgical menopause in Wistar rats

BACKGROUND: Osteoporosis is metabolic skeletal disease characterized with low bone mass, bone microarchitecture disturbance that together lead to high prevalence of fragility fractures. Postmenopausal osteoporosis accounts for about 80% of the osteoporosis structure in women over 50 years. Diabetes mellitus (DM) is an independent risk factor for low-traumatic fractures. The incidence of both type 2 DM and osteoporosis increases during menopause. Therefore, the study of bone metabolism in experimental diabetes and surgical menopause seems important.

THE AIM of the study was to investigate bone metabolism parameters during menopause and experimental type 2 DM.

MATERIALS AND METHODS: The half of female Wistar rats had been subjected to bilateral ovariectomy at the beginning of the experiment. Diabetes mellitus (DM) was modelled using a high-fat diet and streptozotocin+nicotinamide. Four weeks after the following groups were formed: «Сontrol» (females without any interventions receiving standard chew, n=5) «OE» (females after ovariectomy n=5), «DM» (females with DM, n=4), «OE+DM» (females after ovariectomy with DM, n=4). The observation period lasted 8 weeks. Bone turnover and calcium-phosphorus metabolism markers (osteocalcin, osteoprotegerin (OPG), nuclear factor-kappa-beta receptor activator ligand (RANKL), sclerostin, fibroblast growth factor-23 (FGF-23), calcium, phosphorus) were measured in the end of experiment. Bone histomorphometry was performed after euthanasia.

RESULTS: Phosphorus level was significantly lower both in the «OE» group (1.63 [1.58; 1.65] mmol/L) and in the «DM» group (2.81 [2.57; 2.83] mmol /l) compared to the «Control» group (3.12 [2.55; 3.24] mmol/l) (p<0.001). This marker was significantly higher in the «OE+DM» group (2.79 [2.46; 2.81] mmol/l) in comparison to the «OE» group (2.79 [2.46; 2.81] mmol /l), p=0.025. Osteocalcin level was significantly lower in the «DM» group (8.1 [7.8; 9.2] ng/ml) compared to the «Control» group (16.97 [14.07; 17.07] ng/ml ), p=0.005. A weak negative correlation (r= -0.5, p<0,05) was found between glucose and osteocalcin levels (p=0.03). RANKL level was significantly lower in the «OE+DM» group (278,1 [273.1; 289.7] pg/mL) compared to the «OE» group (400.6 [394.5; 415.1] pg/mL), besides the OPG/RANKL ratio was higher in this group (0.03 [0.02; 0.035] and 0.01 [0.004; 0.014], respectively), p=0.05. In the «OE» group lower OPG level (5.1 [1.5; 5.6] pmol/L) and OPG/RANKL ratio (0.01 [0.003; 0.014]) were obtained in comparison to the «Control» group (12.3 [8.8; 14.2] pmol/l and (0.34[0.33; 0.4], p=0.025 and p=0.07, respectively. The area of bone trabeculae in the epiphyseal zone was the largest in the «Control» group (42 [39; 45]) %; the difference was significant compared to the «OE» group (29 [25; 33] %, p=0.011) and the «OE+DM» group (30 [23; 25] %, p=0.016). The area of bone trabeculae in the metaepiphyseal zone was also the largest in the «Control» group (49 [46; 52] %) compared to the «OE» (35 [25; 39] %), «DM» (31 [26; 34] %), «OE+DM» (35 [33; 38] %), p<0.001. There was no difference in the thickness of the bone trabeculae among the groups.

CONCLUSION: DM induction can significantly inhibit bone remodeling in animals without menopause, which is reflected in a lower osteocalcin level. Bone turnover during DM and surgical menopause is characterized by lower RANKL levels and higher OPG/RANKL ratio. The effect of ovariectomy on bone metabolism was manifested in more extensive decrease in bone trabeculae area than in DM.

SGLT-2 Inhibitors' and GLP-1 Receptor Agonists' Influence on Neuronal and Glial Damage in Experimental Stroke

Background: SGLT-2 inhibitors (SGLT-2i) and GLP-1 receptor agonists (GLP-1RA) have demonstrated nephro- and cardioprotective effects, but their neuroprotective properties, especially concerning stroke severity, and mechanisms are not unambiguous. We aimed to study the influence of SGLT-2i with different selectivity and GLP-1RA on brain damage volume and neurological status in non-diabetic and diabetic rats and to investigate the underlying mechanisms. Methods: Non-diabetic Wistar rats were divided into five groups (n = 10 each) and received empagliflozin, canagliflozin, or dulaglutide as study drugs and metformin as comparison drug. Control animals were administered 0.9% NaCl for 7 days before stroke. At 48 h after stroke, we assessed neurological deficit, neuronal and astroglial damage markers, and brain damage volume. We also modeled type 2 DM in Wistar rats using the high-fat diet+nicotinamide/streptozotocin method and established similar treatment groups. After 8 weeks, rats were subjected to stroke with further neurological deficit, neuroglial damage markers, and brain necrosis volume measurement. Results: In non-diabetic rats, all the drugs showed an infarct-limiting effect; SGLT-2i and dulaglutide were more effective than metformin. DULA improved neurological status compared with MET and SGLT-2i treatment. All the drugs decreased neurofilament light chains (NLCs) level and neuronal damage markers, but none of them decreased the glial damage marker S100BB. In DM, similarly, all the drugs had infarct-limiting effects. Neurological deficit was most pronounced in the untreated diabetic rats and was reduced by all study drugs. All the drugs reduced NLC level; dulaglutide and empagliflozin, but not canagliflozin, also decreased S100BB. None of the drugs affected neuron-specific enolase. Conclusions: SGLT-2i and GLP-1RA are neuroprotective in experimental stroke. GLP-1RA might be more effective than SGLT-2i as in non-diabetic conditions it influences both brain damage volume and neurological status. All study drugs decrease neuronal damage, while GLP-1RA and highly selective SGLT-2i EMPA, but not low-selective CANA, also have an impact on neuroglia in diabetic conditions.

Glucose metabolism disorders associated with COVID-19: clinical and morphological study

BACKGROUND. Glucose metabolism disorders (GMD) were detected both in acute and in post-COVID, however, its pathogenic aspects remain unclear.

AIM. To analyze the occurrence of GMD in post-COVID patients who have had moderate and severe COVID-19 without previously known GMD disorders, and evaluate expression of SARS-CoV-2 proteins and its entry factors in pancreas in acute COVID-19.

METHODS. Among 187 hospitalized patients with confirmed COVID-19 141 patients without previously diagnosed GMD underwent follow-up post-COVID visits. The examination for all patients included anthropometric measurement with calculation of BMI, level of HbA1c and fasting plasma glucose, for 106 patients level of insulin and HOMA-IR index was analyzed. For histological examination, pancreas fragments of 20 patients with fatal outcome were selected. Immunohistochemical study was performed with antibodies to SARS-CoV-2, ACE2, DPP4, as well as double-labeled immunofluorescence microscopy (insulin-SARS-CoV-2, insulin-ACE2, insulin-DPP4).

RESULTS. Among 141 patients in post-COVID period, 9 (6.3%) had HbA1c or fasting plasma glucose levels that met criteria for diabetes mellitus, 38 (26.9%) — exceeded normal values (WHO), and 84 (59.6%) had GMD according to criteria of the ADA. In post-COVID, patients with GMD had a higher BMI and HOMA-IR index (p=0.001) compared to patients with normal glycemic levels. Only 40.4% of people had HOMA-IR index above 2.7. Patients with GMD had higher level of CRP (p=0.007) and a maximum glucose level (p=0.019) in the acute period. Positive relationship was found between BMI and HOMA index both in acute (p<0.001; r=0.389) and post-COVID (p<0.001; r=0.412) periods, as well as the level of HbA1c in acute period (p=0.019, r=0.202) and in post-COVID (p=0.004, r=0.242).

Histological and immunohistochemical studies showed the expression of SARS-CoV-2 proteins in 1.85% [0–15.4] and 11.1% [5.3–14.8] cells of the Langerhans islets in patients who died on the second and third waves, respectively. The expression of ACE2 and DPP4 in the islets of Langerhans did not exceed 0.4% [0–1.7] and 0.5% [0–0.8] of cells, respectively. Double-labeled immunofluorescence microscopy showed co-localization of SARS-CoV-2, ACE2, DPP4 with insulin.

CONCLUSION. Post-COVID Glucose metabolism disorders may be explained by direct cytotoxic effect of SARS-COV-2, increased glucose toxicity and insulin resistance because of the acute infection and its complex therapy.

[Vitamin D deficiency in overweight patients: current strategies and practical aspects]

On September 27, 2024, a discussion-based working meeting on the issue of vitamin D deficiency in patients with overweight and obesity was held in Vladikavkaz.The meeting aimed to evaluate the relationship between vitamin D deficiency, overweight, and associated comorbidities, as well as to explore modern strategies and practical approaches for managing such patients in endocrinology practice. The resolution of the meeting was developed by its participants, comprising leading endocrinologists.

Cardiovascular complications in patients with primary hyperaldosteronism

Objective.Primary aldosteronism (PA) is a common reason of secondary arterial hypertension (HTN) and is associated with an increased risk of cardiovascular complications, chronic kidney disease and mortality. The aim of this study was to compare the prevalence of cardiovascular complications in patients with PA and HTN and show the peculiarities of cardiovascular system involvement in hyperaldosteronism.Design and methods.We included 191 (77,0  %) females and 57 (23,0  %) males with suspected PA aged from 19 to 86 years old. Other reasons for secondary HTN were excluded. Diagnosis of PA was based on Endocrine Society recommendations (2009).Results.PA diagnosis was confirmed in 41 (16,5  %) subjects. Systolic blood pressure was higherin patients with PA than in patients with essential hypertension, but diastolic blood pressure did not differ. Microalbuminuria was found in 61,0  % of patients with PA and only in 41,6  % of hypertensive subjects (р < 0,05). Study showed that prevalence of stroke, angina pectoris, myocardial infarction as well as arrhythmia were the same in both patients’ group. On the other hand, 29,3  % with PA had chronic heart disease compared to only 12,0  % among patients with essential HTN (p < 0,05).Conclusions.We showed that HTN associated with autonomic aldosterone production leads to more frequent cardiovascular complications. Hence, early PA diagnosis and treatment is an important approach of modern medicine.

Mood Disorders After COVID-19

Introduction. The COVID-19 pandemic has led to a high prevalence of post-COVID-19 syndrome (PCS), with mood disorders being the most common manifestations. Objective: To study the prevalence of PCS-associated mood disorders and their features. Materials and methods. We examined patients after COVID-19 (n = 91; age: 24-84 years; median time to recovery: 7 months) using the following tools: the BDI and HADS (screening for anxiety and depression); the Starkstein Apathy Scale; FIS and FSS (fatigue assessment); the MoCA, MMSE, and FAB (cognitive assessment); the FIRST, ESS, PSQI, and ISI (sleep disorders evaluation); the EQ5D (quality of life measurement). We designed a special questionnaire to collect data related to a history of COVID-19 and patients' condition after discharge. In addition, we analyzed electronic medical records and discharge summaries and performed neurological examination. Results. Of all the examined patients, 65 (71.4%) participants had signs and symptoms of PCS. Mood disorders were observed in 33 (50.8%) cases, with apathy (78.7%), anxiety (66.7%), and fatigue (60.6%) being the most common. Depressive disorders were found in 12 (36.3%) patients. Cognitive functions were impaired in 7 (21.2%) patients; sleep disorders were observed in 16 (48.5%) cases. We found a positive correlation between depressive disorders and fatigue based on the BDI, FIS, and FSS scores (rS = 0.711; rS = 0.453), depressive disorders and anxiety (rS = 0.366), fatigue and apathy (rS = 0.350). Anxiety increased the risk of sleep disorders (rS = 0.683). Quality of life has been shown to decrease in patients with mood disorders due to the negative effect of long-term fatigue and depressive disorders. Conclusions. There is a close connection between different types of mood disorders that develop after COVID-19 and exacerbate symptoms of each other. Early diagnosis and treatment of these disorders can improve patients' quality of life and preserve their ability to work.

T Regulatory Cell Subsets Do Not Restore for One Year After Acute COVID-19

COVID-19, caused by SARS-CoV-2, triggers a complex immune response, with T regulatory cells (Tregs) playing a crucial role in maintaining immune homeostasis and preventing excessive inflammation. The current study investigates the function of T regulatory cells during COVID-19 infection and the subsequent recovery period, emphasizing their impact on immune regulation and inflammation control. We conducted a comprehensive analysis of Treg subpopulations in peripheral blood samples from COVID-19 patients at different stages: acute infection, early convalescence, and long-term recovery. Flow cytometry was employed to quantify Tregs including "naïve", central memory (CM), effector memory (EM), and terminally differentiated CD45RA+ effector cells (TEMRA). Additionally, the functional state of the Tregs was assessed by the expression of purinergic signaling molecules (CD39, CD73). Cytokine profiles were assessed through multiplex analysis. Our findings indicate a significant decrease in the number of Tregs during the acute phase of COVID-19, which correlates with heightened inflammatory markers and increased disease severity. Specifically, we found a decrease in the relative numbers of "naïve" and an increase in EM Tregs, as well as a decrease in the absolute numbers of "naïve" and CM Tregs. During the early convalescent period, the absolute counts of all Treg populations tended to increase, accompanied by a reduction in pro-inflammatory cytokines. Despite this, one year after recovery, the decreased subpopulations of regulatory T cells had not yet reached the levels observed in healthy donors. Finally, we observed the re-establishment of CD39 expression in all Treg subsets; however, there was no change in CD73 expression among Tregs. Understanding these immunological changes across different T regulatory subsets and adenosine signaling pathways offers important insights into the disease's pathogenesis and provides a broader view of immune system dynamics during recovery.

Vitamin D Metabolism Parameters and Cytokine Profile in COVID-19 Patients with Bolus Cholecalciferol Supplementation

Recent studies have demonstrated the relationship between vitamin D deficiency, infection severity and mortality from COVID-19. This study aimed to analyze the vitamin D metabolites and cytokine expression levels of COVID-19 patients who were hospitalized with bolus cholecalciferol supplementation.

MATERIALS AND METHODS

This study represents the next stage of the open-label randomized pilot conducted by the Almazov National Medical Research Centre. A total of 44 hospitalized patients, comparable in demographic, clinical, laboratory and instrumental baseline characteristics, with moderate/severe COVID-19 were included. All patients had similar doses of concomitant corticosteroid therapy. Twenty-two patients received 50,000 IU cholecalciferol on the first and eighth days of hospitalization. The serum 25(OH)D, 1,25(OH)2D and 28 plasma cytokines were estimated for each group initially and on the ninth day of hospitalization.

RESULTS

Initially, there were no differences in the 1,25(OH)2D and cytokine levels in patients with vitamin D deficiency and normal 25(OH)D. Bolus cholecalciferol therapy at a total dose of 100,000 IU led to an increase in 25(OH)D levels in hospitalized patients with COVID-19, while the levels of the active metabolite (1,25(OH)2D) did not show significant differences between the groups or in its increased level over time, regardless of cholecalciferol supplementation. Furthermore, cholecalciferol supplementation at a total dose of 100,000 IU did not affect the majority of the cytokines estimated on the ninth day of hospitalization, except for the pro-inflammatory marker IL-1b, the concentration of which was lower in the group of patients without vitamin D supplementation.

CONCLUSIONS

The 25(OH)D level was positively associated with an anti-inflammatory immune response, but cholecalciferol supplementation at a total dose of 100,000 IU did not affect the active-form vitamin D or cytokine expression levels. This fact may be explained by the impact of corticosteroid therapy, and it requires further investigation in a post-COVID-19 context.

Insufficiency/deficiency of vitamin B12 in patients in the endocrinological practice

On March 20, 2024, an interdisciplinary meeting of the Expert Council on the current problem of B12 insufficiency/deficiency and the prevalence of this condition among endocrine patients was held at the Endocrinology Research Centre (Moscow). The purpose of the meeting was to assess the role of B12 deficiency in reducing the quality of life of patients of different groups and to outline a strategy for the management of patients with vitamin B12 insufficiency/deficiency by endocrinologists.

The resolution of the expert council was developed by leading specialists in various specialties.

Neuroprotective effects of glucose-lowering drugs in rat focal brain ischemia-reperfusion model

Background.Ischemic stroke is one of the leading causes of death in patients with type 2 diabetes mellitus (DM). According to the results of clinical and experimental studies, the ability of glucagon-like peptide-1 receptor agonists (GLP-1RA) to reduce the risk and severity of stroke in DM has been proven; data on the sodium-glucose cotransporter-2 inhibitors (SGLT-2i) effect are scarce. There has been no direct comparative study of the GLP-1RA and SGLT-2i neuroprotective effect.

Objective.To evaluate and to compare the effect of GLP-1RA of varying duration of action and SGLT-2i of varying selectivity on the neurological deficit severity and the brain damage volume in a transient focal brain ischemia model in rats without DM.

Design and methods.Male Wistar rats were divided into groups (n = 10 each) depending on the therapy received: “EMPA” (empagliflozin per os 2 mg/kg once daily), “CANA” (canagliflozin per os 25 mg/kg once daily), “LIRA” (liraglutide 1 mg/kg s. c. once daily), “DULA” (dulaglutide 0,12 mg/kg s. c. every 72 hours), “SEMA” (semaglutide 0,012 mg /kg s. c. once daily), “MET” (metformin per os 200 mg/kg once daily — comparison group), “Control” (administration of 0,9 % NaCl solution s. c. once daily). After 7 days, all groups underwent transient focal 30-minute filament middle cerebral artery occlusion. After 48 hours of reperfusion, neurological deficit was assessed using the Garcia scale, then the brain was collected and sections were stained with 1 % triphenyltetrazolium chloride solution to calculate the damage volume.

Results.Neurological deficit severity in the “LIRA” (14,50 (12,25; 15,25) points) and “SEMA” (14,00 (13,50; 18,00) points) groups was significantly less than in the “Control” group (11.00 (6,75; 12,00) points). The use of both SGLT-2i, as well as metformin, had no effect on the neurological status. At the same time, therapy with all study drugs had an infarct-limiting effect, compared with the “Control” group (damage volume 24,50 (14,69; 30,12) % of the total brain volume). At the same time, the brain damage volume in the “MET” group (12,93 (6,65, 26,66) %) was greater than that in the “EMPA” (6,08 (2,97, 7,63) %), “CANA” (5,11 (3,96; 8,34) %), “LIRA” (3,40 (2,09; 8,08) %), “DULA” (4,37 (2,72; 5,40) %), “SEMA” (5,19 (4,11; 7,83) %) groups.

Conclusions.SGLT-2i of varying selectivity and GLP-1RA of varying duration of action have a similar infarct-limiting effect in acute experimental brain ischemia. At the same time, GLP-1RA neuroprotective potential is higher, as it is characterized by an additional positive effect on the neurological status.

A.I.Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation, Gorelov A, Malyavin A, A.I.Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation, Babak S, A.I.Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation, Zaitsev A, Academician N.N.Burdenko military Clinical Hospital, Moscow, Russian Federation, Karonova T, V.A.Almazov National Medical Research Center, Saint Peterburg, Russian Federation, Lioznov D, A.A.Smorodintsev Scientific Research Institute of Influenza, Saint Peterburg, Russian Federation, Petrov V, Obninsk Institute of Atomic Energy, National Research Nuclear University "MEPhI", Obninsk, Russian Federation, Pigarova E, National Medical Research Center of Endocrinology, Moscow, Russian Federation, Esaulenko E, Saint Petersburg State Pediatric Medical University, Saint Peterburg, Russian Federation. Expert Consensus Statement Role of vitamin D in the prevention of acute respiratory infections

Acute respiratory viral infections (ARVIs) are the most common respiratory tract diseases that can reduce the quality of life of patients and aggravate bronchopulmonary and cardiovascular diseases. All ARVIs annually lead to a total economic damage of approximately 758 billion rubles, which corresponds to 80% of the damage from all infectious diseases. Due to a relatively limited number of non-specific causal therapy options, specific and non-specific prevention of ARVIs becomes extremely important. However, no specific vaccines against ARVIs, except influenza, have been developed so far. The majority of drugs for ARVI prevention have suboptimal efficacy and weak evidence (grade C). Given the pronounced economic damage from ARVIs (reaching 40 billion rubles annually), as well as the need for effective non-specific preventive agents, it is important to analyze the evidence base of new drugs for non-specific ARVI prevention, assess their cost-effectiveness, and availability for most patients. This can contribute to reducing ARVI incidence and both direct and indirect healthcare costs. Objective. Present the main provisions of the Council of Experts "The role of vitamin D in the prevention of acute respiratory infections" (February 18, 2023, Moscow, Russia) and assess the prospects for using in routine practice for improving the quality of patients life and optimize the costs of health care system. Main points. Preventive doses of colecalciferol (vitamin D3) is associated with a low risk of ARVI with daily or weekly intake lasting from 6 months. Vitamin D3 supplementation of 6 to 12 months should be recommended for people without obesity (BMI<30 kg / m2) in a dose of 2000 IU / day or 10,000 IU / week, and with obesity (BMI>30 kg / m2) in doses from 3000 IU / day to 6,000 IU / day for a long time. Long-term using of preventive doses of vitamin D3 is associated with a necessary maintain its target level throughout the year. Conclusions. In Russian Federation there is a high prevalence of deficiency and insufficiency of colecalciferol (vitamin D3) among the population, regardless of region and age group. According to the results of randomized clinical studies and metaanalyses, daily or weekly intake of vitamin D3 is associated with a low risk of ARVI. At the same time, vitamin D3 has a high therapeutic range, which makes its using more safe. Experts consider it it important to include colecalciferol (vitamin D3) in Russian clinical guidelines "Acute respiratory viral infections (ARVI) in adults" as part of their next revision as a means of non-specific prevention of ARVI. Level of evidence A (higher quality of evidence- 1). Key words: acute respiratory viral infections, influenza, COVID-19, nonspecific prevention, vitamin D3, colecalciferol