Vol 31, No 8 (2024)

Diabetes mellitus (DM) and obesity are one of the most common combinations in the structure of comorbid pathology, which is confirmed by numerous epidemiological data. Both of these diseases are based on primary insulin resistance and develop with the participation of largely identical pathological mechanisms. The relationship of pathogenetic mechanisms allows using an integrated approach to prescribing drugs and achieving target glycemic control and weight loss simultaneously. The article presents the main groups of drugs used in the treatment of obesity in diabetic patients with the determination of optimal combinations depending on the characteristics of the DM course, its complications and concomitant diseases.

Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia. Clinical manifestations of PHPT are represented by classical and non-classical symptoms, among which the most striking are bone manifestations. At the same time, many extraosseous manifestations, including cardiovascular, gastrointestinal, neurocognitive disorders, with which patients often consult a general practitioner, have been described. The review presents the main manifestations that may occur with damage to these systems in PHPT, describes the pathogenetic mechanisms of these manifestations, the effectiveness of surgical treatment of PHPT in relation to the prognosis of extraosseous disorders. The authors identify a group of patients for whom it is advisable to screen for PHPT for its early detection and treatment, which will avoid the progression of clinical manifestations, both bone and extraosseous.

Ensuring control of diabetes mellitus (DM) is impossible without self-monitoring by the patient, which does not lose its relevance in modern conditions. Recommendations for the management of diabetic patients are updated annually, more modern approaches to self-monitoring of glycemia are developed, innovative glucometers are introduced, including systems with a mobile application. The article presents innovative trends in glycemic monitoring using intelligent mobile applications that allow for more effective, including remote, DM management.

Background. Due to the unfavorable prognosis in type 2 diabetes mellitus (DM2), priority is given to prescribing hypoglycemic drugs that not only provide optimal glycemic control, but also have pleiotropic effects.

Objective. Evaluation of the non-glycemic benefits of using a fixed combination (FC) of alogliptin and pioglitazone in real clinical practice in diabetic patients who have not achieved carbohydrate metabolism compensation with metformin monotherapy.

Methods. Thirty DM2 patients were examined, including 18 men and 12 women, aged 22 to 72 years (mean age 50.9 ± 11.4 years). Anthropometric parameters, glycated hemoglobin levels, fasting plasma glucose, postprandial glucose, lipid spectrum parameters were assessed; glomerular filtration rate (GFR) and the liver fibrosis index were calculated. The analyzed parameters were recorded initially and 6 months after adding of FC alogliptin 25 mg and pioglitazone 30 mg to metformin (average dose 2000 mg/day).

Results. After 6 months, treatment with FC of alogliptin and pioglitazone resulted in an effective decrease in glycemic control and peripheral tissue insulin resistance, favorable changes in lipid metabolism with a positive effect on the calculated liver fibrosis index and GFR levels.

Conclusion. FC of alogliptin and pioglitazone not only provide optimal glycemic control, but also is capable of exerting a number of pleiotropic effects on cardiovascular diseases and non-alcoholic fatty liver disease.

Background. Arterial hypertension (AH) and type 2 diabetes mellitus (DM2) are often combined and mutually enhance the adverse effect on vascular and renal prognosis. In patients with such comorbidity, a comparative assessment of the capabilities of individual representatives of the basic classes of antihypertensive drugs seems important, which can increase the effectiveness of treatment programs.

Objective. Prospective study of tolerability, hypotensive and organoprotective effects of the combination of azilsartan and spironolactone in patients with AH and DM2.

Methods. A randomized comparative prospective study of the tolerability and safety of two antihypertensive therapy regimens in patients with AH and DM2 was conducted for 12 months. The planned follow-up period was completed by 71 patients (38 men and 33 women), mean age – 65.6 ± 11.8 years. Randomization was carried out by the envelope method: group A (azilsartan at doses of 40–80 mg/day in combination with spironolactone 25–50 mg/day) and group B (ramipril 5–10 mg/day with indapamide 1.5–2.5 mg/day). Diagnosis of AH and DM2, as well as their complications, was based on the relevant domestic and international recommendations. Based on generally accepted approaches, general clinical and biochemical studies were performed, blood pressure (BP) was assessed in the doctor’s office and using ambulatory BP monitoring (ABPM); the left ventricular myocardial mass index and the common carotid artery intima-media thickness were determined.

Results. Treatment in both groups was associated with a statistically significant decrease in systolic and diastolic BP (SBP and DBP, respectively). In group A, compared with group B, the hypotensive effect was more significant and developed faster. The degree of decrease in office SBP in group A over this period was 42.3 ± 8.4 mm Hg (25.0 ± 5.0% of the initial value), in group B – 29.3 ± 6.2 mm Hg (17.6 ± 4.1%), respectively. For DBP, similar values were 23.1 ± 5.6 mm Hg in group A (23.5 ± 4.3%), in group B – 12.6 ± 2.8 mmHg (13.0 ± 2.4%), all P < 0.05. A more pronounced hypotensive effect of treatment in group A compared to group B was also noted according to ABPM data. During treatment, favorable changes in cardiovascular remodeling were recorded in both groups, they were more significant in group A.

Conclusion. In patients with a combination of arterial hypertension and type 2 diabetes mellitus, a wider use of azilsartan, which has high hypotensive efficacy and additional favorable properties, in combination with the mineralocorticoid receptor antagonist spironolactone is justified.

Background. Chronic pelvic pain in endometriosis is accompanied by high levels of stress and anxiety.

Objective. Evaluation of the norepinephrine, adrenaline levels in the peripheral blood of patients with chronic pelvic pain and endometriosis.

Methods. A comparative analysis of the results of assessing blood catecholamine levels and stress levels was performed in 40 women (18-45 years old) with endometrioid ovarian cysts suffering from chronic pelvic pain and neuropathy.

Study design: comparative prospective study.

Results. Patients with chronic pelvic pain associated with endometriosis had high blood catecholamine levels compared with the control group and the group with painless endometriosis (p < 0.05).

Conclusion. High levels of stress, anxiety and depression in patients with CPP and endometriosis maintain high blood levels of adrenaline and norepinephrine, aggravating chronic pain.

Background. Lipid metabolism disorders are observed in 60–70% of patients with obesity. Type 2 diabetes mellitus (DM2) is an independent risk factor for cardiovascular disease and is associated with increased cardiovascular risk. The presence of DM2 and hyperlipidemia determines the target group of patients for taking statins. However, at present, the prescription and administration of lipid-lowering therapy (LLT) remain unsatisfactory, and adherence to statin therapy also remains quite low. Bariatric surgery is currently becoming widespread due to its effectiveness in achieving DM2 remission. However, there are currently no recommendations regarding statin therapy in patients after bariatric interventions; clinical studies on this topic are few.

Objective. Evaluation of the blood lipid profile in patients with obesity and DM2 and without DM2 before and after bariatric surgery (BS).

Methods. An observational prospective study of 211 patients with grade I–III obesity was conducted. Patients were recruited from January 2018 to April 2023. Of the 211 patients enrolled in the study, 99 had confirmed type 2 diabetes, including 63 women and 36 men. All patients underwent gastrectomy (longitudinal gastrectomy – LG - or gastric bypass – GB – using the standard technique). All patients had their lipid profile assessed before gastrectomy and in the plateau phase. Cardiovascular risk was assessed to determine the patient’s need for LLT.

Results. In the study group of patients (n = 211), LLT was indicated in 163 (77.3%) patients, but only 36 (22%) of these patients received statins. Among diabetic patients (n = 99), LLT was received by 23 (23.2%) patients. The total cholesterol (TC) level in patients not receiving statin therapy was 5.0 ± 0.9 mmol/L, low-density lipoprotein (LDL) – 2.8 ± 0.8 mmol/L. In patients receiving LLT, the TC and LDL levels were slightly lower: TC – 4.6 ± 1.0; LDL – 2.4 ± 0.8 mmol/L (P> 0.05). Among obese patients with DM2, 42 (42.4%) patients underwent LG, 57 (57.6%) patients underwent GB. Among obese patients without DM2, 98 (87.5%) patients underwent LG, 14 (12.5%) patients underwent GB. In the group of patients without DM2 who underwent LG and GB, the TC level significantly decreased after BS (P < 0.05), and the LDL levels also slightly decreased. In the group of patients with DM2, a significant decrease in the TC and LDL levels was noted in the LG and GB groups (P < 0.05), both operations were comparable in terms of the decrease in the TC and LDL levels (P> 0.05). The achievement of target LDL values after BS was also assessed: in the group of patients with obesity and DM2, target LDL values were achieved by 65 patients (85.5%), in the group of patients with obesity without DM2 – 88 (88.9%). No significant differences were obtained between LG and GB in achieving target LDL values.

Conclusion. Metabolic surgery allows achieving a significant reduction in TC levels in obese patients with and without DM2, as well as LDL levels in obese diabetic patients.

Diabetes mellitus (DM) is a chronic metabolic disorder characteristic of a global pathology that entails hyperglycemia and complications at both the micro- and macrolevels. According to the World Health Organization (WHO), about 600 million people worldwide suffer from diabetes today, and the number of such patients will increase to 1.5 billion by 2050. In Russia, there are 10-12 million diabetic patients, and about half of them remain undiagnosed (according to the materials of the A.I. Yevdokimov Moscow State University of Medicine and Dentistry, during a speech at the XXXI Russian National Congress «Man and Medicine»). The main share falls on type 2 diabetes mellitus, which is widespread and accounts for 90% of cases. In light of the continuous increase in the number of people with diabetes, the need for sufficient and high-quality glycemia monitoring has increased dramatically, prompting the creation of new methods for monitoring blood glucose levels. Maintaining glycemic concentrations in the target range is necessary to prevent serious complications. Optimization of the glycemic profile is becoming a key factor in successful diabetes management. This literature review is devoted to the analysis of adherence to modern methods of glucose control in diabetic patients with, including the identification of significant aspects and influencing factors.

Achieving and maintaining target values of glycemic control remains an urgent task in the treatment of patients with both type 1 diabetes mellitus (DM1) and type 2 diabetes mellitus (DM2). At the present stage, in addition to the glycated hemoglobin level, new indicators of glucose control have appeared associated with the introduction of the method of continuous glucose monitoring in patients. Particular attention is paid to the indicators of glycemic variability (GV). In DM1 patients, therapy with intermediate-acting insulins and their peak-acting analogues does not fully mimic endogenous insulin secretion, increases the risk of hypoglycemia and may be associated with an increased incidence of GV. DM2 patients more often require higher doses of insulin, the use of which is also associated with high GV. GV can be considered as a risk factor for hypoglycemia and vascular complications. The emergence of new-generation insulins with a long action that do not have an absorption peak can reduce GV. Insulin degludec (Tresiba®) is a long-acting basal insulin analogue (with an action duration of more than 42 hours), which was specially developed for low variability of action. This article considers a series of clinical cases of DM1 and DM2 patients being switched to insulin degludec therapy due to ineffective previous treatment with insulin detemir.

Multiple pituitary hormone deficiency is characterized by insufficient production of two or more pituitary hormones and can develop as a result of birth trauma, asphyxia, and defects in genes that control pituitary cell differentiation during embryonic development. Variant substitutions in the PROP1 gene are the most common genetic cause of multiple pituitary hormone deficiency. The gene, mapped independently in 1998 by two groups of scientists, is located on the long arm of chromosome 5 (5q35) and consists of three exons. Homeodomain transcription factor consisting of 226 amino acids is the gene product that plays a decisive role in the differentiation of the adenohypophysis with the formation of five cell types (somatotrophs, lactotrophs, thyrotrophs, gonadotrophs, corticotrophs). Variant substitutions in PROP1 are autosomal recessively inherited, the phenotype of the disease is heterogeneous. The onset of tropic deficiencies in most cases is described in the following order: secondary hypothyroidism, somatotropic hormone (STH) deficiency, secondary hypogonadism, and in some cases – secondary hypocorticism. The role of pituitary hormones in the functioning of the body is multifaceted. Growth hormone and thyroid hormones (THs) produced under the influence of thyroid-stimulating hormone have, among other things, a great influence on lipid metabolism. Excess of STH and THs leads to a decrease, and their deficiency – to an increase in all blood lipid fractions, which increases the risk of developing cardiovascular complications, dyslipidemia in this case is secondary. This article describes a clinical case of severe hyperlipidemia that developed in a non-compliant patient with a compound heterozygous variant in the PROP1 gene.

Modern practical healthcare has many unsolved problems regarding diagnostics, including differential ones, of various nosologies, as well as optimal tactics for managing comorbid patients; in connection with which it is important to use an individual approach to each patient. The presented clinical case demonstrates the development of pancreatogenic diabetes mellitus due to exacerbation of chronic pancreatitis. The complexity of diagnostics consisted of understanding the true cause of the increase in blood glucose levels. It should be emphasized that newly diagnosed hyperglycemia requires consultation by an endocrinologist, but hyperglycemia is not always a direct cause of the deterioration of the patient’s condition. The final clinical diagnosis was established by a consultation involving a therapist, endocrinologist, gastroenterologist, emergency physician and nephrologist. Based on the results of the consultation, complex therapy was prescribed to reduce the severity of inflammatory processes in the pancreas, liver and kidneys, normalize blood glucose levels, and reduce symptoms. This clinical case shows importance of a multidisciplinary approach to the patient is, since most often older patients are comorbid patients. The lack of regular monitoring and timely correction of treatment can significantly worsen the quality of life and reduce the life expectancy of patients.

The integration of artificial neural networks (ANNs) into clinical decision support systems based on health information systems represents a transformative shift in healthcare technologies that improves clinical decision making using advanced machine learning techniques. This evolution has arisen in response to the growing complexity and volume of medical data, which requires more sophisticated decision support tools that can provide personalized recommendations and improve patient outcomes. Neural networks, characterized by their ability to learn from large data sets, have played a critical role in developing predictive models that identify patient risks and suggest solutions, optimizing clinical workflows and improving the quality of care. The use of ANNs has sparked debates about the effectiveness, usability, and ethical implications of artificial intelligence (AI)-based decisions in healthcare. Research has shown significant improvements in predictive accuracy compared to traditional rule-based systems, but challenges in their implementation, including data quality, algorithmic bias, and the need for transparency in AI decision-making processes remain. The shift from traditional decision-making approaches to neural network-based systems is intensifying the debate around trust and explainability in healthcare technologies. While ANNs offer promising advances in medical decision-making, their black-box nature raises concerns about the reliability and transparency of the recommendations they generate among healthcare providers. Addressing these issues is essential to ensuring the integration of ANNs into healthcare information systems, ultimately aiming to provide equitable and effective patient care. As the field continues to evolve, ongoing and emerging research is critical to improving, mitigating potential biases, and enhancing the functionality of ANN-based clinical decision support systems. The convergence of AI and healthcare heralds a new era that has the potential to revolutionize clinical practice, but also requires careful consideration of the ethical implications and adherence to fundamental principles of patient care.