[Determination of prolactin reference intervals in different age groups]

BACKGROUND

Clinical diagnostic laboratories (CDL) have at their disposal various automated systems for the measurement of biochemical parameters and markers such as prolactin. Each of the test systems manufactures offers its own alternate design of the method, which makes standardization difficult. In endocrinological practice, the problem of result discrepancies often arises. In hormonal assays, the clinical picture of patients sometimes does not correspond to the reference values provided by the manufacturers, which determines the need to develop the method-specific reference values for a specific population. The difficulty in interpreting basal prolactin levels is not only due to a transient increase in the hormone levels caused by stress or excessive physical exertion, but also due to a significant variability of indicators in the same patient, even if all recommendations for blood sampling are followed.

AIM

The aim of the study to determine the reference values in serum samples of women, men and children of different age groups for the VITROS Immunodiagnostic Systems and compare the results with the "expected prolactin levels" recommended by the method manufacturerMATERIALS AND METHODS: The monocentric study included 879 serum samples of apparently healthy subjects who were admitted to the Endocrinology Research Center. Measurements were performed using the VITROS ECi 3600 automatic chemiluminescence analyzer (Ortho-Clinical Diagnostics, Great Britain).

RESULTS

For adult men and women reference values were 66-436 and 94-500 mIU/l respectively. When comparing the results of prolactin determination in women and men of the studied cohort with the "expected values" of the VITROS ECi 3600 manufacturer a systematic shift towards an increase in lower and upper limits of the reference values was found in both -cohorts.

CONCLUSION

The obtained reference values of prolactin can be use in the determination of prolactin in the Russian population for VITROS ECi 3600 Immunodiagnostic Systems.

[Alemtuzumab-induced Graves' disease]

Multiple sclerosis (MS) is a severe chronic autoimmune demyelinating disease of the central nervous system, mediated by Th1/Th17 lymphocytes as well as B lymphocytes, macrophages and other immune cells. Some patients with MS are treated with alemtuzumab, a monoclonal antibody against CD52+ cells, which belongs to the disease-modifying therapies (DMTs). The main effect of alemtuzumab is related to changes in immune recruitment. Alemtuzumab therapy can induce secondary autoimmunity against the background of immune rebalancing. The thyroid gland is generally involved in the autoimmune process. Graves' disease (GD) develops most often, followed by autoimmune thyroiditis.We present a clinical case of a patient with GD developed after alemtuzumab therapy for MS. The patient was referred to a radiologist at the Department of Radionuclide Therapy of Endocrinology Research Centre for radioiodine therapy (RAIT) due to relapse of thyrotoxicosis after anti-thyroid drug therapy for GD. The goal of treatment was achieved in 2 months, thyroid hormone therapy was initiated, against the background of this, there was compensation of thyroid function.

[FGF23 tumor induced osteomalacia]

Tumor induced osteomalacia is a rare acquired disease. The cause is a mesenchymal tumor secreting fibroblast growth factor 23 (FGF23). An excessive amount of FGF 23 disrupts the metabolism of phosphorus and vitamin D, which leads to severe paraneoplastic syndrome, manifested in the form of multiple fractures, severe pain in the bones and generalized myopathy. With oncogenic osteomalacia, a complete cure is possible with radical resection of the tumor. Unfortunately, localization, small size of formations and rare frequency of occurrence lead to the fact that the disease remains unrecognized for a long time and leads to severe, disabling consequences. A step-by-step approach to diagnosis improves treatment outcomes. First, a thorough anamnesis is collected, then functional visualization is performed and the diagnosis is confirmed by anatomical visualization of the tumor. After that, the method of choice is a surgical treatment. If resection is not possible, then conservative therapy with active metabolites of vitamin D and phosphorus salts is indicated. New therapeutic approaches, such as the antibody to FGF23 or the pan-inhibitor of receptors to FGF, are actively developing. This article provides an overview of modern approaches to the diagnosis and treatment of this disease.

[Treatment of Graves' disease in patients with thyroid eye disease]

Graves' disease (GD) is an autoimmune disease that is often complicated by thyroid eye disease (TED). Clinical presentations of TED can develop simultaneously with the manifestation of GD, after the manifestation of GD amid treatment, and before the development of thyrotoxicosis. Treatment of such patients is a difficult task, because on the one hand, it is necessary to take into account the clinical picture of thyrotoxicosis, and on the other - the symptoms of eye damage. The combination of the two pathologies determines the need for simultaneous treatment of GD and TED, and the choice of a treatment method for GD will depend on the manifestations of TED. This article presents current views on the treatment of GD with concomitant TED. The choice of GD treatment method will be largely determined by the clinical manifestations of TED and will be conducted jointly by endocrinologists and ophthalmologists.

Adiponectin: a pleiotropic hormone with multifaceted roles

Adipose tissue mostly composed of different types of fat is one of the largest endocrine organs in the body playing multiple intricate roles including but not limited to energy storage, metabolic homeostasis, generation of heat, participation in immune functions and secretion of a number of biologically active factors known as adipokines. The most abundant of them is adiponectin. This adipocite-derived hormone exerts pleiotropic actions and exhibits insulin-sensitizing, antidiabetic, anti-obesogenic, anti-inflammatory, antiatherogenic, cardio- and neuroprotective properties. Contrariwise to its protective effects against various pathological events in different cell types, adiponectin may have links to several systemic diseases and malignances. Reduction in adiponectin levels has an implication in COVID-19-associated respiratory failure, which is attributed mainly to a phenomenon called 'adiponectin paradox'. Ample evidence about multiple functions of adiponectin in the body was obtained from animal, mostly rodent studies. Our succinct review is entirely about multifaceted roles of adiponectin and mechanisms of its action in different physiological and pathological states.

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.

[Review of clinical practice guidelines for hypoparathyroidism]

Hypoparathyroidism is a rare disorder characterized by the absent or inappropriately decreased serum parathyroid hormone in the parathyroid glands, which is accompanied by impaired calcium-phosphorus metabolism.The main etiology of hypoparathyroidism remains damage or removal of the parathyroid glands during neck surgery. In view of the incidence of thyroid cancer, primary hyperparathyroidism and other pathologies of the neck organs, which radical treatment can lead to the parathyroid gland impairment, an increased number of patients with hypoparathyroidism is expected. Autoimmune hypoparathyroidism is the second most common form of the disease, usually occurring as part of type 1 autoimmune polyglandular syndrome. Autoimmune hypoparathyroidism usually occurs in childhood and is characterized by a severe course of the disease, especially in the case of concomitant malabsorption syndrome.Chronic hypoparathyroidism of any etiology requires lifelong multicomponent therapy, as well as careful monitoring and an individual approach to choose the optimal treatment strategy. In the absence of adequate follow-up, the risks of long-term complications significantly increase, particularly in the renal, cardiovascular systems; in the soft tissues and in the brain, it could lead to visual disturbances; pathology of the musculoskeletal system with a decreased bone remodeling and a potential risk of fractures, as well as to the neurocognitive disorders and an impaired health-related quality of life.Timely diagnosis, rational medical therapy and management strategy may reduce the risks of short-term and long-term complications, frequency of hospitalizations and disability of patients, as well as improve the prognosis.This review covers the main issues of Russian guidelines for the management of chronic hypoparathyroidism, approved in 2021, including laboratory and instrumental evaluation, treatment approaches and follow-up. This guidelines also include the recommendations for special groups of patients: with acute hypocalcemia, hypoparathyroidism during pregnancy.

[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.

[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.

[Molecular genetic markers and criteria for the prediction of adrenocortical carcinoma]

Studies of the last decade have demonstrated that the morphological and immunophenotypic patterns of adrenocortical carcinoma (ACC) have a high heterogeneity in both the occurrence of various tumors and the development of a solitary tumor. Carcinogenesis of ACC, like most neoplastic processes, is associated with mutations in at least 15 driver genes, with a wide range of chromosomal aberrations, epigenomic changes, and alterations of the microRNA profile. According to the literature, isolated genetic damage is also insufficient for the manifestation of the malignant phenotype of adrenocortical cells. Knudson's two-hit hypothesis is implemented in at least germline mutations: the development of ACC requires a second genetic event occurring in somatic cells, which leads to inactivation of the second allele of the gene. ACC is an extremely heterogeneous disease, which determines the complexity of differential diagnosis with benign adrenocortical tumors and that of prediction of the clinical course. Another no less important issue is the lack of valid predictors for the efficacy of mitotane, the use of which may be associated with severe adverse effects.

[Current aspects of diagnosis and treatment of adult GH-deficiency]

Adult growth hormone (GH) deficiency (AGHD) is a condition characterized by alterations in body composition, lipid and carbohydrate metabolism, bone mineral density and poor quality of life; however, clinical presentations of AGHD are mostly non-specific. Untreated AGHD is associated with increased cardiovascular morbidity and mortality. Stimulation tests are used for the diagnosis: insulin tolerance test, glucagon stimulation test, growth-hormone releasing hormone and arginine stimulation test. Moreover, in 2017 FDA approved the use of macimorelin (oral GH secretagogue) for the diagnosis of AGHD. In childhood GH-deficiency, apolipoprotein A-IV, CFHR4 (complement factor H-related protein 4) and PBP (platelet basic protein) were identified as potential biomarkers of the disease, however, this was not investigated in AGHD. GH treatment starts from the minimal dose, which allows minimizing the adverse effects. According to published meta-analyses, AGHD treatment generally does not lead to increased risk of malignancy and recurrence of sellar neoplasms in adult patients. Published data on GH receptor polymorphism associations with treatment efficacy remains controversial. Development of long-acting GH formulations is a currect perspective for the increase of treatment compliance.

[Expression of plasma microRNA in patients with acromegaly]

BACKGROUND

microRNA is a class of small non-coding RNA molecules involved in posttranscriptional regulation of gene expression. MicroRNAs are detectable in blood in stable concentrations, which makes them promising biomarkers for various diseases.

AIM

to assess plasma microRNA expression in patients with active acromegaly compared with healthy controls.

MATERIAL AND METHODS

single-center, case-control study: assessment of plasma microRNA in patients with acromegaly compared with healthy controls. Fasting blood samples were drawn and centrifuged at +5С temperature and 3000 rpm for 20 minutes, then aliquoted and frozen at 80C until further analysis. MicroRNA extraction and library preparation was done according to manufacturers instructions. Expression analysis was performed on NextSeq sequencer. Bioinformatic analysis using atropos (adapted deletion), STAR (aligning), FastQC (quality control), seqbuster/seqcluster/miRge2 (microRNA annotation, isomiR and new microRNA search, expression analysis). Primary endpoint of the study differential expression of plasma microRNA in patients with acromegaly compared with healthy controls.

RESULTS

we included 12 patients with acromegaly age 33.1 [20; 47], BMI 29.3 kg/m2 [24.0; 39.6], IGF-1 686.1 ng/mL [405.9; 1186.0] and 12 healthy subjects age 36.2 [26; 44], BMI 26.7 kg/m2 [19.5; 42.5], IGF-1 210.4 ng/mL [89.76; 281.90]; gender ratio for both groups 4 males, 8 females. The groups did not differ in gender (p=0.666), age (p=0.551) and BMI (p=0.378). We found decreased expression of four microRNAs in patients with acromegaly: miR-4446-3p 1.317 (p=0.001), miR-215-5p 3.040 (p=0.005), miR-342-5p 1.875 (p=0.013) and miR-191-5p 0.549 (p=0.039). However, none of these changes were statistically significant after adjustment for multiple comparisons (q 0.1).

CONCLUSION

we found four microRNAs, which could potentially be downregulated in plasma of patients with acromegaly. The result need to be validated using different measurement method with larger sample size.

Restoration of fertility in a woman with giant prolactinoma in response to cabergoline treatment

SUMMARY

A 32-year-old woman presented with primary amenorrhoea, prolactin (PRL) level of 154 150 mIU/L and was diagnosed with a giant pituitary adenoma measuring maximum 6.2 cm. Cabergoline (CAB) treatment at a dose of 0.5 mg/week was prescribed to the patient. The treatment decreased the tumour size after 3 months (MRI scans of the brain) and brought back to normal the level of the PRL (345 mIU/L) after 6 months of CAB treatment. After 7 months of CAB treatment, menarche was achieved, and after 12 months, the patient became pregnant. She discontinued taking CAB at 4-week gestation. The pregnancy resulted in a missed miscarriage at 6-7 weeks; an abortion was conducted by the vacuum aspiration method. The MRI scans of the brain did not show any tumour enlargement. After 18 months from the start of the treatment the patient got pregnant for the second time. At 25-week gestation an MRI scan of the brain was conducted which did not show any increase in the tumour size. At 38 weeks the patient delivered a healthy full-term girl via C-section. The patient chose not to breastfeed and resumed CAB therapy after the delivery. During the treatment, the PRL level returned to the normal range and the menstrual cycle was restored. After 3 years the patient got pregnant for the third time. The patient did not receive CAB during the pregnancies; the examination did not show any tumour enlargement. Further MRI scans did not show any tumour growth. CAB therapy was effective in normalization of the PRL level, tumour shrinkage, menarche and pregnancy-induction which led to the birth of healthy children in a woman with primary amenorrhoea and a giant prolactinoma invading the skull base bones.

LEARNING POINTS

Giant prolactinomas are very rarely found in women. Cabergoline therapy can be effective in the normalization of the PRL level, tumour shrinkage, menarche induction in a woman with primary amenorrhoea, and giant prolactinoma. Cabergoline therapy can be effective in pregnancy induction which leads to the birth of children in a woman with giant prolactinoma. Cabergoline discontinuation did not trigger tumour enlargement during pregnancy.

[Current criteria for the diagnosis of adrenocortical carcinoma]

Adrenocortical carcinoma is a rare malignant tumor of the adrenal cortex with an unfavorable prognosis. In 2017, the International Agency for Research on Cancer (IARC) and the World Health Organization (WHO) published the 4th edition of the WHO Classification of Tumors of Endocrine Organs. The updated classification reflects a multidisciplinary experience in diagnosing and predicting the course of adrenal cortex tumors, obtained on the basis of current studies. This paper highlights the key provisions of the updated WHO classification for adrenocortical carcinoma.

[Role of microRNA in oncogenesis of pituitary tumors and their practical significance]

Microribonucleic acids (miRNAs) are a class of noncoding RNAs that regulate posttranscriptional gene expression. These molecules are regulators of cell proliferation, metabolism, apoptosis, and differentiation. MiRNAs are not degraded by RNAases and their concentrations can be measured in different body fluids, including serum. The expression of miRNAs varies in intact tissues and tumors, including pituitary adenomas. Pituitary tumors are encountered in 22.5% of the population and, in a number of cases, may be asymptomatic, but in case of invasion or/and hormone overproduction, their clinical presentation is severe with multiple symptoms leading to disability and even death. The mechanisms for the development and progression of pituitary tumors and the markers for remission and recurrence have not been adequately investigated. This literature review discusses the biological significance of miRNAs in pituitary tumors and the potential value of circulating miRNAs as biomarkers.

[Long-term consequences of polycystic ovary syndrome]

Polycystic ovary syndrome (PCOS) is the most common chronic endocrine disease in women. The prevailing complaints at a young age are menstrual irregularities, infertility, and hyperandrogenism-related problems. However, metabolic disorder-induced complications have been in the foreground over years. The review gives the current ideas on a change of clinical manifestations in the natural course of PCOS, as well as the pathogenetically grounded prevention of complications in patients.

Effects of endogenous hypercortisolism on bone mRNA and microRNA expression in humans

Hypercortisolism in humans suppresses osteoblastogenesis and osteoblast function through the upregulation of Wnt-signaling antagonists (sclerostin, Dkk1) and changes in microRNAs levels (miR-125b-5p, miR-218-5p, miR-34a-5p, miR-188-3p, miR-199a-5p) which are associated with mesenchymal stem-cell commitment to adipocytes or cartilage cells over the osteoblasts.

INTRODUCTION

The purpose of this study was to evaluate the responses of bone to chronic glucocorticoid (GC) excess by measuring the levels of selected mRNA and microRNA (miR) in bone samples of patients with Cushing's disease (CD).

METHODS

Bone samples were obtained during transsphenoidal adenomectomy from the sphenoid bone (sella turcica) from 16 patients with clinically and biochemically evident CD and 10 patients with clinically non-functioning pituitary adenomas (NFPA) matched by sex, age, and body mass index. Quantitative polymerase chain reactions (qPCR) were used to examine the expression of genes (mRNA and miRs) known to be involved in bone remodeling regulation based on studies in animals and cell culture.

RESULTS

Hypercortisolism was associated with the downregulation of genes involved in osteoblast function and maturation (ACP5, ALPL, BGLAP, COL1A1, COL1A2, BMP2, RUNX2, TWIST1). An excess of GC caused increased expression of Wnt-signaling antagonists (Dkk1, SOST) and changes in the levels of miRs that are known to suppress osteoblastogenesis (miR-125b-5p, miR-218-5p, miR-34a-5p, miR-188-3p, miR-199a-5p) p < 0.05, q < 0.1. Interestingly, compensatory mechanisms were found in long-term hypercortisolism: upregulation of Wnt10b, LRP5, and LRP6; downregulation of SFRP4; changes in miRs involved in osteoblastogenesis (miR-210-5p, miR-135a-5p, miR-211, miR-23a-3p, miR-204-5p); and downregulation of genes associated with osteoclastogenesis. None of these changes prevented the suppression of bone formation.

CONCLUSIONS

An excess of endogenous GC in humans suppresses bone formation through the upregulation of Wnt-signaling antagonists and dysregulation of miRs involved in mesenchymal stem-cell commitment. Both Wnt-signaling antagonists and miRs seem to be promising targets for further research in therapeutic intervention in glucocorticoid-induced osteoporosis.

[Shereshevsky-Turner syndrome: Estrogen replacement therapy and cardiovascular risk factors]

AIM

To investigate the impact of menopausal hormone therapy (MHT) on the expression of risk factors for cardiovascular events (CVEs) in patients with Shereshevsky-Turner syndrome (STS); to elaborate an algorithm for patient management using MHT.

SUBJECTS AND METHODS

From 2010 to 2012, a total of 41 patients aged 14 to 35 years with STS were examined in the framework of a prospective observational study. 100 STS case histories in 2000 to 2009 were retrospectively analyzed. The indicators of the so-called cardiometabolic risk, such as body mass index (BMI), lipidogram readings, venous plasma glucose levels, and blood pressure, were estimated in relation to the type of MHT. In the prospective part of the investigation, an angioscan was used to estimate vessel characteristics (stiffness, wall tone, endothelial function (EF)), by using the examination data.

RESULTS

90% of the patients with STS were found to have risk factors for CVEs: atherogenic dyslipidemia (85%; 51% in the general female population of the same age), diastolic hypertension (36%; no more than 5% that is not typical for age-matched healthy general female population). In addition to increased arterial wall stiffness (AWS), obvious EF disorder is typical for STS patients. MHT was accompanied by a dose-dependent (estradiol, at least 2 mg) reduction in diastolic blood pressure by an average of 13% over 24 months, an increase in high density lipoprotein levels by more than 10% over 24 months and also contributedto a decrease in AWS and an improvement in EF.

CONCLUSION

By favorably affecting the EF of vessels and reducing the severity of atherogenic dyslipidemia, MHT potentially enables a reduction in CV risk in patients with STS.

[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.

The canonical Wnt/β-catenin pathway: From the history of its discovery to clinical application

The Wnt/β signaling pathway (Wnt-SP) is a phylogenetically ancient mechanism that regulates development and maintains tissue homeostasis through the control of cell proliferation, differentiation, migration, and apoptosis. The accurate regulation of the canonical Wnt/β-catenin signaling pathway (Wnt-SP) is critical for embryogenesis and postnatal development; and impaired signal transduction at one of its stages leads to various diseases, including organ malformations, cancers, metabolic and neurodegenerative disorders. The literature review discusses the biological role of the canonical Wnt-SP in the development of the skeleton and in the remodeling of bone tissue. The Wnt signal transmission changes observed during genetic mutations cause various human skeletal diseases. Understanding the functional mechanism involved in the development of bone abnormality could open new horizons in the treatment of osteoporosis, by affecting the Wnt-SP. The design of antibodies to sclerostin, a Wnt-SP inhibitor, is most promising now. The paper summarizes the studies that have investigated the canonical Wnt-SP and designed drugs to treat osteoporosis.

[Familial partial lipodystrophy (Dunnigan syndrome) due to LMNA gene mutation: The first description of its clinical case in Russia]

Hereditary lipodystrophies (HLD) are a heterogeneous group of rare diseases characterized by a complete or partial loss of subcutaneous fat and by the development of metabolic disturbances: diabetes mellitus with obvious insulin resistance and acanthosis nigricans, dyslipidemia, hepatic steatosis, hypertension, and polycystic ovary syndrome. The laminopathy variant familial partial lipodystrophy type 2 or Dunnigan syndrome (FPLD2) is the most common cause of partial LD. The paper describes a family (3 clinical cases) with FPLD2 caused by heterozygous R482W missense mutations in the gene encoding the protein lamin A/C (LMNA; 150330). This observation demonstrates that specialists should be more aware of this disease and make a timely diagnose in cases of concurrent severe metabolic disturbances at a young age, which contributes to more effective treatment of patients and to medical genetic counseling of their families.

Cushing’s disease: the clinical features, diagnostics, differential diagnostics, and methods of treatment

The present guidelines on diagnostics, differential diagnostics, and methods of treatment of Cushing’s disease have been developed by a group of Russian specialists.

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.

[Carbohydrate metabolism in patients with acromegaly and Itsenko-Cushing disease]

The relevance of investigating carbohydrate metabolism (CM) in patients with acromegaly and Itsenko-Cushing disease is attributable to frequent glucose metabolic disturbances, on the one hand, and to difficulties in choosing sugar-lowering therapy in these categories of patients, on the other. The efficiency of hyperglycemia treatment in these patients may be reduced due to problems in achieving remission/cure of the underlying disease and to specific therapy favoring hyperglycemia. The top-priority tasks are to search for ways of reducing the frequency of CM abnormalities in patients with neuroendocrine diseases and to elaborate sugar-lowering therapy regimens. There is a growing interest in studies of the role of the incretin system in the pathogenesis of secondary hyperglycemias associated with neuroendocrine diseases. Nevertheless, few works have been published on this subject matter because of its novelty. There is a need for a further closer study of the specific features of incretin system function and the pharmacodynamics of incretin mimetics that are potential candidates as first-line drugs to treat secondary hyperglycemias. This paper attempts to summarize the available data obtained from studies into CM in neuroendocrine diseases.

Federal clinical practice guidelines on the diagnostics and treatment of adrenocortical cancer

Statement of hormonal activity and potential malignancy are the most important issues of diagnosis and selection of appropriate treatment way for patients with adrenal tumors. Adrenal cortical carcinoma (ACC) is rare disease with poor prognosis. Incidience of ACC is about 0.5-2 per million, and no more then 2-4% among adrenal tumors. This draft of guidelines of diagnosis and treatment of ACC is offered to common discussion among wide round of specialists.

Endocrine and reproductive abnormalities in the men treated for medulloblastoma and acute lymphoblastic leukemia in the childhood

Leukoses and tumours of the central nervous system (CNS) are the leading malignant neoplasms encountered in the childhood. The combined treatment of these diseases including radiotherapy and polychemotherapy may have negative consequences for the functioning of the male reproductive system. The objective of the present study was to estimate the influence of therapy of acute lymphoblastic leukemia (ALL) and malignant tumours of the posterior cranial fossa (PCF) in the childhood on the endocrine and reproductive systems of the adult men. The study included 17 male patients who had undergone the treatment of PCF neoplasms and 6 men after therapy of ALL. The most widespread disorders in the patients of the former group were the small testicle size and the low inhibin B level. The combined treatment of PCF tumours produced a more pronounced adverse gonadotropic effect than ALL therapy.

[Pathophysiological aspects of wound healing in normal and diabetic foot]

The main cause of long-term healing of ulcers in patients with diabetic foot is considered to be direct mechanical damage when walking due to reduced sensitivity to due to neuropathy, hyperglycemia, infection and peripheral artery disease. These factors determine the standard approaches to the treatment of diabeticfoot, which include: offloading, glycemic control, debridement of ulcers, antibiotic therapy and revascularization. Recently, however, disturbances in the healing process of the skin in diabetes recognized an additional factor affecting the timing of healing patients with diabetic foot. Improved understanding and correction of cellular, molecular and biochemical abnormalities in chronic wound in combination with standard of care for affords new ground for solving the problem of ulcer healing in diabetes.

[Features of the mental state of obese patients with concomitant sleep disorders]

OBJECTIVE

To study the frequency of mental disorders with concomitant insomnia in obese patients.

MATERIAL AND METHODS

Authors studied 123 patients (51 men and 72 women, mean age 40.0±11.5; body mass 117.6±30.9 kg; waist circumference 118.2±19.8 cm; BMI 39.8±8.7 kg/m2) with obesity.

RESULTS

The questionnaire survey revealed subjective disorders of the quality of sleep in 76%, complaints about snoring in 63%, hypersomnia during the day in 55% higher risk of sleep apnea in 50%, insomnia in 45% of patients. According to the results of psychological testing, the obese patients with insomnia had higher levels of health anxiety.

CONCLUSION

Insomnia can be considered as a marker of overt psychopathological disturbances in patients with obesity.

Serum extracellular secreted antagonists of the canonical Wnt/β-catenin signaling pathway in patients with Cushing's syndrome

Patients with endogenous hypercortisolism have higher sclerostin, but do not differ in Dickkopf 1 (Dkk1) or secreted frizzled-related protein 1 (SFRP1) levels as compared to healthy control.

INTRODUCTION

Endogenous Cushing's syndrome (CS), usually affecting young and otherwise healthy patients, is a good model to validate the effects of supraphysiological levels of glucocorticoids in humans. This study evaluates circulating levels of extracellular antagonists of the Wnt/β-catenin signaling pathway (sclerostin, Dkk1, SFRP1) in patients with CS versus healthy individuals.

METHODS

Forty patients with clinically and biochemically evident CS and 40 sex-, age-, and body mass index-matched healthy subjects provided fasting serum samples for sclerostin, SFRP1 and Dkk1, along with bone turnover markers.

RESULTS

Patients with CS had higher sclerostin levels (34.5 (30.3-37.1) pmol/L) versus healthy individuals (29.9 (24.3-36.8) pmol/L) (p = 0.032). Differences in sclerostin were due to the lack of lower sclerostin values rather than an increase in protein levels above the upper limits of the healthy control. The odds of sclerostin levels being higher than 30 pmol/L were greater in patients with CS as compared with the odds in healthy subjects (odds ratio = 3.81 95 % confidence interval 1.45-10.02) (p = 0.01). It coexisted with suppressed bone formation and unchanged bone resorption markers. Dkk1, SFRP1 did not differ from the control group.

CONCLUSIONS

Of all the tested proteins (sclerostin, Dkk1, SFRP1), only sclerostin showed a significant difference when contrasting CS with healthy subjects. Hypercortisolism might prevent the down-regulation of sclerostin. Targeting sclerostin seems to be a promising therapeutic approach to treating osteoporosis in patients with CS.

Metabolic complications of endogenous Cushing: patient selection for screening

Aims: this study evaluates the most common associations of symptoms and complications in patients with Cushing’s syndrome (CS) in order to choose a potential population to be screened for CS and estimates the diagnostic accuracy of first line screening tests (cortisol, ACTH) to differentiate ACTH-ectopic CS from Cushing’s disease. Materials and Methods: The clinical data of 259 patients with proven CS during 2001–2011 was analyzed. The clinical presentations of 197 patients (159 Cushing’s disease, 28 ACTH-ectopic CS and 10 cases of benign cortisol-secreting adrenal adenoma) were compared according to the cause of hypercortisolism. ROC-analysis was performed to estimate the diagnostic accuracy of the first line tests (cortisol, ACTH) to suggest ACTH-ectopic CS. A threshold for the test with the highest area under the curves was chosen based on the maximum sum of the sensitivity and specificity. Results: The most frequent complaints were related to fatigue, muscle weakness, weight gain and changes in appearance (facial plethora and fullness, striae). Among the complications of CS the most frequent were being overweight or obese (71%), hypertension (63%), dislipoproteinemia (41%), low traumatic fractures (43%) and steroid-induced diabetes (31%). In women, 16% were older than 50, in those who were younger amenorrhea was registered in 43%. The patients with ACTH-ectopic CS had higher rate of low traumatic fractures (p=0.04), increased serum late-night cortisol, 24 hours urinary free cortisol, morning and evening ACTH and lower levels of potassium (p0.01 for all parameters). Plasma late-night ACTH measurements showed the highest AUC (0,811 (95% CI 0,712–0,909)) to differentiate ACTH-ectopic CS from Cushing’s disease. A cut off value of 108.9 pg/ml for late-night ACTH yielded a sensitivity of 60,7% and a specificity of 79%. Conclusions: patients with a coexistence of obesity, muscle weakness, fatigue, some components of metabolic syndrome and especially low traumatic fractures should be screened for CS. High plasma late night ACTH values in patients with proven CS value suggest ACTH-ectopic syndrome.

[Russian consensus on the diagnosis, treatment, and monitoring of acromegalia (draft)]

Acromegaly is a serious disease of the hypothalamic-pituitary system, caused by chronic overproduction of growth hormone (GH) in individuals with completed physiological growth, affecting mainly people of working age. The disease is characterized by significant disability of patients and a reduction in life expectancy, the main reasons for which are complications caused by prolonged hypersecretion of GH. These include primarily damage to the cardiovascular system, respiratory system, metabolic disorders, malignant neoplasms of the gastrointestinal tract. At the same time, timely diagnosis and adequate treatment can reduce mortality several times, significantly improve the quality of life of patients.Until now, the problem of optimizing the diagnosis of acromegaly, especially the so-called "soft" form, as well as the choice of the most effective and safe treatment method, is relevant all over the world and in our country in particular.At the V Russian Congress of Endocrinology, a draft consensus on the management of patients with acromegaly was discussed. Subject to the provisions of the international agreement and Russian experience, recommendations are offered for the diagnosis, treatment and monitoring of this disease for further discussion, followed by the adoption of a final consensus.

[Influence of clinical and subclinical thyrotoxicosis on the adult skeletal system]

This review analyzed information on the effect of manifest and subclinical thyrotoxicosis on the bone system of adults.

[Elevated level of methylated catecholamine derivatives is a pathognomic laboratory sign of pheochromocytoma]

The levels of the methylated catecholamine derivatives (MCD) metanephrine and normetanephrine were measured in 46 patients operated on. The patients were divided into 2 groups: 1) 24 patients in whom chromaffinoma was histologically detected; their age varied from 9 to 75 years (mean 37.8 years); 2) 22 patients who had undergone adrenal cortical tumors or retroperitoneal tumors of extraadrenal genesis; their age ranged from 11 to 67 years (mean 44.3 years). In this group of patients, a histological study revealed aldosteromas in 7 cases, hormonally inactive adrenal cortical adenomas in 6, adrenocortical carcinoma in 5, corticosteroma in 1, adrenal lymphosarcoma in 1, adrenolypoma in 1, and renal cancer in 1. In all the patients from Group 1, there was an increase of one MCD index for instance of less than 110% of the upper normal range. The average excess of MCD levels over the upper normal range is 456% for metanephrine and 574% for normetanephrine. No increase in the level of daily MCD excretion was found in 21 out of the 22 Group 2 patients with nonchromaffin adrenal and retroperitoneal tumors. In this group, 1 patient with histologically verified mixed-cell adenocarcinoma of the adrenal cortex was observed to have a daily metanephrlne excretion increase by 17% above the upper reference range. Thus, the sensitivity of the method was 100%; its specificity was 95.5%. The lower confidence diagnostic interval for the values of daily MCD excretion was 714 ng/day for metanephrlne and 1500 ng/day for normetanephrine. The procedure for determining free MCD in plasma has a high sensitivity and specificity and may be once used as a screening for the symptomatic nature of disease in patients with arterial hypertension.

[The etiology and pathogenesis of primary chronic adrenal insufficiency: Current aspects]

Primary chronic adrenal insufficiency is a relatively rare disease. To date, according to various authors, the prevalence of Primary chronic adrenal insufficiency in the world varies significantly.

[Subacute thyroiditis]

Subacute thyroiditis (de Kerven's thyroiditis, giant cell thyroiditis, granulomatous thyroiditis) - a self-limiting inflammatory disease of the thyroid gland (thyroid gland), presumably of viral etiology, is the most common cause of pain in the thyroid gland. The disease (probably without an autoimmune component) is characterized by a 4-phase course (thyrotoxicosis, euthyroidism, hypothyroidism and restoration of normal functioning of the thyroid gland), its duration is from several weeks to several months. The subacute thyroiditis was first described by de Kerven in 1904. In most cases, if the disease has a characteristic clinical picture, the diagnosis of subacute thyroiditis is not difficult and, with adequate treatment, the patient will recover completely.

[Current views of the effects of thyroid hormones and thyroid-stimulating hormone on bone tissue]

The relationship between thyroid pathology and bone tissue was first noticed as early as 1891, when Recklinghausen described multiple fractures in a patient with untreated thyrotoxicosis. Despite the fact that in the modern etiological and pathogenetic classification of osteoporosis, thyrotoxicosis is included in the group of secondary osteoporosis, various aspects of the action of thyroid hormones on bone tissue continue to be studied to this day. The purpose of this review is to discuss the mechanisms of the influence of thyroid hormones on bone and, to a greater extent, to analyze new information on the biological and clinical significance of TSH for bone tissue. The review also provides information on the physiology of bone remodeling and the mechanisms of activation of receptors for thyroid hormones and TSH, which is necessary for a more complete understanding of hypotheses that explain the possible ways TSH affects bone cells.

[Choice of optimal gestagen for combined hormonal replacement therapy in the peri- and postmenopause]

Menopause, being the end of the reproductive period of a woman's life, is characterized by changes in the endocrine balance in the body, significantly affecting health, quality of life and general life prognosis. These changes can be more significant and even take on a fatal character with "forced", artificial (surgical) menopause.

[Clinical guidelines developed by the Russian Association of Endocrinologists for the diagnosis and treatment of nodular goiter]

The guidelines presented do not pretend to be a systematic presentation of all aspects of the diagnosis and treatment of nodular goiter and are not intended to replace guidelines for various medical disciplines. In real clinical practice, situations may arise that are beyond the scope of the recommendations presented, in connection with which the final decision regarding a specific patient and responsibility for him lies with the attending physician.The recommendations presented are mainly devoted to the diagnosis and treatment of nodular (multinodular) euthyroid colloid, differently proliferating goiter in adults (over 18 years of age) and are the agreed opinion of the RAE experts who developed them. Nodular (multinodular) toxic goiter, tumors (malignant and benign), as well as other diseases that can manifest themselves by nodular formations of the thyroid gland (thyroid gland), are discussed mainly in the context of differential diagnosis. The recommendations also do not affect the features of diagnosis and treatment of nodular goiter in children and adolescents.

[Results of epidemiological surveys for iodine-deficiency diseases within the framework of the Thyromobile project]

In the Russian Federation, there are virtually all areas whose population is at risk for iodine-deficiency disorders. During 2003, we made epidemiological studies of iodine-deficiency disorders within the framework of the Thyromobile project supported by the pharmaceutical company "Nycomed"in 12 regions of the Russian Federation. A total of 2673 individuals were examined. According to the WHO recommendations, the study covered prepubescent children aged 8 to 11 years. It involved physical examination, thyroid ultrasound study, blood sampling for ioduria, intelligence test, and sodium chloride iodine assay. The findings indicated that the tension of goiter endemia corresponded to the level of iodine deficiency, which was in the range of mild iodine deficiency, in most regions other than some districts of the Volgograd, Astrakhan, Nizhni Novgorod regions where the median of ioduria in schoolchildren corresponded severe iodine deficiency. The studies indicated that the population's use ofiodinated salt is not up to the recommendations of international expert organizations. Intelligence tests revealed an 11-18% IQ decrease in children from virtually all study areas. According to the strategy of iodine deficiency control in the Russian Federation, it is advisable to use iodinated salt for mass prevention and drugs containing a physicological dose of iodine for group and individual prevention.

[Long-term results of treatment of toxic goiter with radioactive 131I]

The study included 103 patients with toxic goiter, among whom 75 patients were diagnosed as having Graves' disease (GD) and 28 had thyroid functional autonomy (FA) that was presented with toxic multinodular goiter in most cases. All the patients received 131I therapy, then they were followed up; the duration of the follow-up of the patients in whom euthyroidism was preserved at the moment this paper was being written was 18 [10; 28] months. The treatment of GD in 86.7% of the cases ended either with hypothyroidlsm (53.4%), recurrent thyrotoxlcosls (33.3%), or with euthyroidism (13.3%). In FA, recurrent thyrotoxlcosls developed statistically less frequently (10.7%; p = 0.041) and a euthyrold state was statistically more frequent (46.4%; p < 0.001). It was concluded that the optimal purpose of 131I therapy for GD was to destroy the thyroid gland and to achieve persistent hypothyroidlsm, but, in FA, to achieve either euthyroidism or hypothyroidlsm. The use the relatively low activities of 131I (on the basis of the estimated absorbed dose of 100-200 Gy) was demonstrated to be accompanied by a high (33.33%) risk for recurrent thyrotoxlcosls. The volume of the thyroid gland is the major predictor of the late outcome of 131I therapy; but the high level of free T4 after 1 month of 131I therapy and/or the necessity of temporary use of thyrostatlc therapy Involve a high risk for recurrent thyrotoxlcosis.

Parlodel treatment of uremic hypogonadism in men

Parlodel, 2.5 mg daily, was given during 1-3 months to 14 uremic hypogonadal patients (placebo controlled in 6). Except for a decrease in serum prolactin levels on Parlodel (p less than 0.01), no significant changes in hormonal values (gonadotropins and testosterone) were observed either on Parlodel or on placebo. Parlodel treatment improved the potency of 10 patients, eliminated gynecomastia in 2 and normalized spermatogenesis in 6; the best results were obtained in patients on low-protein diet. On placebo, potency improved only in 1 patient; no improvement in spermatogenesis was registered. Thus, Parlodel can improve sexual function and spermatogenesis in hypogonadal uremic males.