[Psychopathological syndromes with sleep disorders in patients with type 2 diabetes mellitus]. / Psikhopatologicheskie sindromy s rasstroistvami sna u patsientov s sakharnym diabetom 2-go tipa.

Sleep disorders are very common in patients with type 2 diabetes (T2DM) and psychiatric disorders. Sleep disturbances can be both an independent condition and are one of the symptoms in the structure of a psychopathological syndrome. The negative impact of sleep disorders and mental disorders on the course of T2DM is known from numerous publications. This article presents current information on the mutual influence of mental disorders and sleep disorders on the course and prognosis of T2DM.

[Manifestation of Graves' disease, resulting from radiosurgical treatment of acromegaly, in a patient with panhypopituitarism].

Cases of thyrotoxicosis associated with a previous case of secondary hypothyroidism are extremely rare. This article presents a rare clinical case of Graves' disease manifestation in a patient with secondary hypothyroidism after radiosurgical treatment of acromegaly. A 38-year old woman presented with acromegaly and endo-supra-laterosellar pituitary adenoma. After non-radical removal of the pituitary adenoma, radiosurgical treatment of the of the residual tissue of the pituitary tumor in the cavernous sinus area was performed. After 14 months of radiation therapy, the acromegaly was in remission; after 24 months of radiation therapy, panhypopituitarism developed (secondary hypothyroidism, adrenal insufficiency, hypogonadism, and growth hormone deficiency). Furthermore, 1.5 years after the panhypopituitarism was diagnosed, the manifestation of Graves' disease was also noted, requiring thyrostatic and radioactive iodine treatments. Diagnostic criteria for secondary hypothyroidism are low levels of the thyroid hormones free T4 and free T3, with a reduced, normal or slightly elevated level of thyroid stimulating hormone (TSH). The criterion for the development of thyrotoxicosis in the context of the secondary hypothyroidism was the persistent increase in the level of free T4 despite adequate drug therapy with levothyroxine. In the case report, the patient's diagnosis of Graves' disease was confirmed by the presence of a high level of antibodies to the TSH receptor.

[Pretibial myxedema: pathogenetic features and clinical aspects].

Pretibial myxedema (PTM) or thyroid dermopathy is a rare extrathyroidal manifestation of Graves' disease. The condition is accompanied by mucinous skin changes, mainly in the anterior tibial surface. Severe forms may lead to lymphatic congestion and disability. Prolonged and intense autoimmune aggression is supposed to be necessary for PTM manifestation. However, data on the role of TSHR antibodies in the development of thyroid dermopathy are very ambiguous; evidence of IGF-1 receptor involvement in the pathogenesis was reported recently. Typically, PTM is localized on the anterior and lateral surfaces of both tibias and can be represented by diffuse, tumorous, plaque-like, or elephantiasic forms. Currently, early diagnostics involves regular preventive examination of the pretibial area. A diagnostic biopsy is indicated only in complex cases. Maintaining euthyroidism, smoking cessation, preventing injuries, and avoiding tight shoes that disturb lymphatic drainage are measures reducing the risk of PTM in GD patients. Currently, there are no accepted clinical guidelines for the diagnosis and treatment of thyroid dermopathy. This review provides the recent scientific data on etiopathogenesis and management of patients with PTM.

[Virilizing ovarian tumor: the challenges of differential diagnosis].

SertoliLeydig cell tumor is a rather rare type of ovarian neoplasms belonging to the group of sex cordstromal tumors. This malignancy is characterized by androgen overproduction, which results in the so-called virilization and can be accompanied by various metabolic disorders such as abdominal obesity, disturbances of carbohydrate and protein metabolism, and high blood pressure. During differential diagnosis, it is important to identify the source of androgen overproduction. An androgen-secreting ovarian tumor needs to be differentiated from androgen-secreting adrenal tumor, ovarian stromal thecomatosis (hyperthecosis), and endogenous hypercorticism (the Cushings syndrome). In most cases, the SertoliLeydig cell tumor is associated with DICER1 mutation carriership. If a patient is found to carry the DICER1 mutation, patients relatives need to undergo genetic testing as the individuals with mutations in this gene have an elevated risk of developing a broad range of benign and malignant tumors (most of these tumors are relatively rare in the overall population). The awareness of this rare ovarian neoplasm among medical specialists (obstetriciansgynecologists, endocrinologists, and oncologists) is supposed to ensure timely diagnosis and adequate treatment of this disease.

[Dynamics of prevalence of functional thyroid dysfunctions among pregnant women in Moscow from 1999 to 2008].

The objective of this study was to study dynamics of prevalence of functional thyroid dysfunctions among pregnant women. The levels of TSH, free T4, and antithyroid peroxidase antibodies (ATP-AB) were measured in randomly selected women of different gestational age who applied to be registered in a maternity welfare centre in 1999-2003 (n = 215) and 2006-2008 (n = 325). The available data indicate that iodine consumption by the study populations increased during the above periods even if still remains subnormal. No statistically significant decrease in the occurrence of ATP-AB and hypothyroidism was recorded. Women carrying ATP-AB in the first and seconds trimesters of pregnancy had significantly higher TSH levels compared to those without ATP-AB. A change of diagnostic criteria for hypothyroidism (lowering the reference TSH threshold from 4.0 to 2.5 mU/l accounts for a several-fold rise (by a factor of 2-7) in the prevalence of hypothyroidism among pregnant women.

[Postpartum thyroiditis: risk factors, differential diagnosis, clinical features].

Postpartum thyroiditis (PT), one of the commonest causes of disturbed thyroid function (TF), is believed to occur in 5% of the women. The present study involving 57 patients with PT was designed to study risk factors and clinical features of this pathology as well as approaches to its diagnosis. Two control groups comprised female carriers of anti- thyroid peroxidase antibodies (TPO-AB) without PT and women having symptoms of Graves disease (GD) in the postpartum period, respectively. Patients with PT were shown to have significantly elevated TPO-AB levels during pregnancy compared with controls. Postpartum GD manifested itself later than PT, it was associated with a significantly higher freeT4 level and a greater thyroid volume. In twenty of the 57 women with PT, it was manifest in the thyrotoxic phase and in the remaining 37 in the hyperthyroid state. The TSH level in the first half of pregnancy was significantly higher in the women that eventually developed a monophasic hypothyroid variant of PT. In the same group, the TPO-AB level at the time of PT diagnosis was significantly higher than in the biphasic variant of PT. Forty (70%) of the 57 women with PT recovered to an euthyroid state by the end of the study whereas in 17 (30%) hypothyroidism persisted. The biphasic variant of PT was manifest starting from the thyrotoxic phase and more frequently ended in the recovery to the euthyroid state (90%) than the monophasic one, the difference being statistically significant. In contrast, the monophasic hypothyroid variant more frequently resulted in persistent hypothyroidism (40%).

[Risk factors of thyrotoxic cardiomyopathy].

A retrospective study covered 272 patients (mean age 54 years) admitted for different forms of toxic goiter concurrent with cardiac arrhythmias and/or sings with heart failure (HF), which was undertaken to explore risk factors of thyrotoxic cardiomyopathy (TTCM). Cardiac arrhythmias following the pattern of sinus tachycardia and/or supraventricular extrasystole without signs of HF were observed ПРОБЛЕМЫ ЭНДОКРИНОЛОГИИ. 2007. Т. 53, № 4. in S3 (19.5%) out of the 272 patients (a mild TTCM group - TTCM-1) whereas cardiac arrhythmias as atrial fibrillations and/or flutters and/or the devebpment of HF In the presence of thyrotoxicosis (TT) were detected in 219 (80.5%) of the 272 patients (a severe TTCM group - TTCM-2). Indices, such as admission age, an interval between TT detection and the initiation of treatment, a history of endocrine ophthalmopathy and cardiovascular pathology, were examined in the regression analysis considering the severe course of TTMC as a poor predictor. Comparison of the groups revealed statistically significant differences in such Indices, as the interval between TT identification to therapy (OR = 1.8; 95% CI = 1.06-3.13; p = 0.02) and the patients' age at the moment of admission (OR = 1.1, 95% CI = 1.02-1.15; p= 0.01).

[Medical treatment for Graves' disease: principles, markers of a relapse and remission].

Graves' disease (diffuse toxic goiter) is a systemic autoimmune disease that develops as a result of the production of antibodies to the thyroid stimulating hormone receptor (AT-rTSH), which is clinically manifested by thyroid damage with the development of thyrotoxicosis syndrome in combination with extrathyroid pathology (pretibial endocrine) myxedema, acropathy). The disease was first described by S. Ives in 1722, then Peri in 1786 and Flayani in 1802. In 1835, R. Graves associated the occurrence of the described symptom complex, now known as thyrotoxicosis syndrome, with thyroid pathology. In 1840, K. Bazedov singled out a triad in the clinical picture: goiter, buccalis, tachycardia.

[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.

[Replacement therapy for hypothyroidism with thyroid hormonal drugs: one or two hormones?]

In recent years, along with a large number of works devoted to the problem of subclinical hypothyroidism, the first studies have appeared that raise the problem that was actively discussed in the 70s at the current methodological level - what is the place of L-T3 drugs in hypothyroidism replacement therapy, and does monotherapy L -T4 advantages over combination treatment. Over the past few years, publications have appeared in the literature in which the authors, citing their own clinical experience in the treatment of patients with hypothyroidism, speak out in favor of the combination therapy of L-T3 and L-T4. This review is devoted to a comprehensive analysis of research results in this area.

[Thyroid-stimulating hormone receptor antibodies in the differential diagnosis of toxic goiter].

The production of stimulating thyroid-stimulating hormone (TSH) receptor antibodies (TSHR-Ab) whose level measurement has come into clinical use underlies the pathogenesis of Graves'disease (GD). This paper deals with the diagnostic and differentially diagnostic value of measurement of TSHR-Ab levels using two first-generation techniques (with heterological TSH): radioreceptor assay ("CIS bio international", France) and enzyme immunoassay ("Medizym" T.R.A."). The levels of TSHT-Ab, as well as thyroid peroxidase antibodies (TH-Ab) and thyroglobulin antibodies (TG-Ab) were studied in 206 patients among whom 176 patients were diagnosed as having GD and 30 had clinical thyroid functional autonomy (FA) generally appeared as multinodal toxic goiter. A comparative analysis of these two assays did not reveal some advantages of them and their results showed a significantly positive correlation (r = 0.91; p < 0.001). The diagnostic sensitivity of the assays was about 80-88% and their specificity was 60-70%. The findings led to the conclusion that in the absence of significant endocrine ophthalmopathy (EOF), clinical and routine instrumental and laboratory studies fail to differentiate GD and throid FA to sufficient accuracy whereas the measurement of the levels of TSHR-Ab substantially makes diagnosis easier. Moreover, it has been shown that the determination of the level of TBII using the test systems containing heterological TSH may not be used for the evaluation of the course of EOF.

[Thyroid cancer].

The prevalence of nodular lesions of the thyroid gland (thyroid gland), according to various researchers, ranges from 3 to 7%]. The widespread introduction of ultrasound (ultrasound) in clinical practice, as well as the results of autopsy studies, showed that the prevalence of nodular lesions of the thyroid gland is much higher and is about 50%, especially at the age of over 50. In women, thyroid nodes are detected 2-4 times more often than in men. Children suffer from nodular lesions extremely rarely. The incidence of nodular goiter is directly proportional to age. The increase in the incidence of nodular goiter is approximately 0.1% per year at a young age and gradually reaches 2%. The prevalence of thyroid cancer (thyroid cancer) among nodular goiter, according to various authors, is from 1 to 6%. It should be noted that the prevalence in the population of nodular goiter is so high both in the regions of iodine deficiency and with normal iodine supply, but in the first case it is slightly higher. The incidence of thyroid cancer in absolute terms does not depend on the level of iodine supply. Thus, in a situation of a slightly higher incidence of banal nodular colloid goiter in the regions of iodine deficiency, the proportion of cancer among all cases of nodular goiter will be less. It is important to note that these data make it possible to equally use the results of studies on thyroid cancer obtained in regions with different iodine supply.

[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.