Сердечно-сосудистые осложнения, включая нарушение ритма и проводимости сердца (НРПС), являются одной из основных причин высокой летальности при акромегалии, однако в настоящее время недостаточно изучены. Цель. Оценить частоту аритмий у пациентов с акромегалией, выявить факторы риска, способствующие развитию НРПС, определить роль магнитно-резонансной томографии (МРТ) сердца в выявлении структурных и функциональных изменений. Материалы и методы. Проведено одноцентровое проспективное когортное исследование, в которое включен 461 пациент (151 мужчина и 310 женщин) с акромегалией. Всем пациентам проведено стандартное медицинское обследование, включающее гормональное исследование крови, регистрацию электрокардиограммы (ЭКГ), эхокардиографию, холтеровское мониторирование ЭКГ. МРТ сердца с контрастированием гадолинием выполнено 18 пациентам с НРПС (11 мужчин и 7 женщин). Результаты. Результаты нашего исследования демонстрируют высокую встречаемость НРПС среди пациентов с акромегалией – 42%. Наиболее частыми видами являлись синусовая брадикардия – 19,1% случаев, а также нарушения проводимости по ножкам пучка Гиса – 14,5%. Мужчины чаще страдали НРПС, чем женщины (54,2 и 37,4% соответственно, р =0,0005). Мы показали, что развитие НРПС зависит, в первую очередь, от длительности акромегалии, в то время как активность заболевания не оказывает значимого влияния. Анамнез акромегалии у пациентов с НРПС и без них составил 10 и 7 лет соответственно ( p =0,04). Кроме того, важным фактором риска оказалась терапия аналогами соматостатина. Доля пациентов, получающих данный вид лечения, составила 50% с НРПС и 38,6% среди пациентов без НРПС ( р =0,004). Мы продемонстрировали, что 61% пациентов с акромегалией и НРПС, которым провели МРТ сердца, имели признаки фиброза миокарда. При этом значение фракции выброса левого желудочка по данным МРТ оказалось статистически выше, чем при эхокардиографии ( p =0,04). Заключение. НРПС часто встречаются у пациентов с акромегалией, несмотря на достижение ремиссии заболевания. Группа высокого риска требует более тщательной диагностики и мониторинга. МРТ сердца является «золотым стандартом» визуализации структурно-морфологических изменений сердца. Проведение МРТ сердца у пациентов с акромегалий расширяет наше представление о развитии НРПС при данном заболевании. В настоящее время отсутствуют специфические лабораторные маркеры диффузного миокардиального фиброза, а его роль в возникновении нарушений ритма и проводимости сердца требует дальнейшего изучения.

Diabetic neuroosteoarthropathy (Charcot’s osteoarthropathy, DNAP, Charcot’s foot) is a common complication of diabetic neuropathy, which can be easily diagnosed in clinical practice and usually is corrected without leading to severe deformation of the affected joint in case of timely and adequate treatment. We present the result of long-term clinical observation of a patient with early development of complications of type 2 diabetes mellitus, diabetic dermatopathy, common DNOAP with damage to the joints of the feet, ankles, knees and elbows. A feature of the described clinical case is the prevalence of osteoarticular disorders with seizure of atypical diabetes zones – knee and elbow joints, the defeat of which is more characteristic of other diseases (such as collagenoses and syphilis), as well as a combination of DNOAP with diabetic dermatopathy. It seems that the causes of such a common arthropathic process lie in the long course of diabetic neuropathy, which debuted long before the diagnosis of type 2 diabetes, as well as the development and progression of this patient in the last decade of observing diabetic nephropathy and associated secondary hyperparathyroidism. In the modern literature, descriptions of combinations of dermatopathies with other complications of diabetes mellitus are extremely rare, and references to a combination of common DNAP and diabetic bullosis have not been found.

BACKGROUND: Diabetic neuroosteoarthropathy (DNOAP, Charcot’s foot) - is a progressive destructive inflammatory disease of the osteoarticular apparatus of the foot, untimely and inadequate treatment of which can lead to the formation of gross deformities. More often, DNOAP is unilateral, bilateral lesion is relatively rare. It is not always possible to trace the relationship between the debut of DNOAP with trauma and chronic hyperglycemia. There is data demonstrating the role of individual pro-inflammatory factors in the pathogenesis of DNOAP, however, studies combining the evaluation of various metabolic markers of Charcot’s foot formation are currently extremely poor. AIM: To evaluate the hormonal and metabolic markers of bone formation and resorption in patients with DNOAP and without this diabetic complication. METHODS: A prospective, controlled trial included 70 patients with type 2 diabetes mellitus (37 men and 43 women) who formed 2 groups: group 1 included patients with DNOAP, group 2 was formed by patients with diabetes without foot skeleton damage. All patients underwent a study of 1,25-OH-vitamin D, sclerostin, pro-MMP-1, C-terminal propeptide type 1 collagen (PICP), type 1 collagen, osteocalcin, PTH, 25-OH-vitamin D, beta-cross-slaps. RESULTS: The results of the studies confirmed the presence of vitamin D deficiency in all patients with diabetes mellitus included in the study, revealed the absence of statistically significant differences between the groups in the values of sclerostin, pro-MMP-1; 25-OH-vitamin D, type I collagen, and osteocalcin (p > 0.05). However, significant differences were found in the 1.25-OH vitamin D levels: patients with DNOAP presented the lower rates of 1,25-OH-vitamin D in comparison to control group (p <0.05). Beta-cross and PICP levels were significantly higher in DNOAP patients as well (p <0.05). Those findings show the more severe collagen degradation in patients with DNOAP and can be the genetically predisposed cause of DNOAP development. Though further studies are needed. CONCLUSION: In patients with DNOAP a decrease in 1,25-OH-vitamin D levels was found, as well as the alteration of the synthesis and destruction of collagen (beta-cross-slaps and PICP) compared to patients with diabetes mellitus without osteoarticular disorders.

Hyperprolactinemia (HP) is one of the most common neuroendocrine disorders. In 60% of cases, pathological HP is caused by pituitary prolactin-secreting adenoma. Therapy with agonists of dopamine type 2 receptors (D2 receptor agonists) is a method of choice for the treatment of pathological HP which allows to achieve prolactin normalization and reduction of pituitary adenoma in most cases. However, 15-20% of patients are resistant to D2 receptor agonists, and the question of overcoming this resistance is highly relevant. Different approaches are considered to solve this problem, one - is to increase the dose of D2 receptor agonists up to the maximally tolerated. In this article, we present a clinical observation of a patient with a partial resistance to D2 receptor agonists who demonstrated a good response to treatment with high doses of cabergoline.

We do not recommend population screening for diabetes insipidus (DI) (B3). We recommend to perform diagnostic testing for central diabetes insipidus (CDI) in patients who underwent neurosurgery, after skull and brain trauma, subarchnoid hemorrhage (B3). We recommend excluding thirst impairment during all stages of diagnostic assessment (С3). We recommend excluding DI in cases of persistent hypotonic polyuria: excretion of more than 3 L. or more than 40 mL/kg of urine daily; urine osmolality less than 300 mOsm/kg or urinary specific gravity less than 1004 g/L in all urine samples or during Zimnitsky test (В3). After hypotonic polyuria is confirmed, we recommend excluding of the main causes of nephrogenic diabetes insipidus (NDI) (B3). We recommend simultaneous measurement of urine osmolality and blood osmolality/sodium level in order to confirm DI. Blood hyperosmolality (more than 300 mOsm/kg) and/or hypernatremia with low urine osmolality (less than 300 mOsm/kg) confirms DI (B2). If testing does not reveal these findings, we recommend performing a fluid deprivation test to exclude primary polydipsia (PP) (B2). Desmopressin test is recommended to distinguish CDI and NDI (B2). In cases of CDI we recommend to perform head MRI with contrast (B3). In cases of NDI we recommend assessing renal structure and function and possible electrolyte disturbances (C3). In cases of PP we recommend to refer a patient to psychiatrist (B3). We recommend treating CDI with synthetic vasopressin analogue – desmopressin (B1). We recommend an individual approach in choosing desmopressin dosage form (B2). As the initial dose is difficult to predict when starting desmopressin treatment, we recommend titrating the dosage using two approaches: “the average dose” and “as required” (C4). We recommend educating the patients to ensure knowledge of the features of various desmopressin dosage forms (C4). To decrease the risk of water intoxication, we recommend educating the patients to the water intake regimen adherence (С4). When CDI is accompanied by thirst impairment, we recommend titrating the dose in a clinical setting, with assessment of blood sodium, bodyweight and/or urine volume (C4).

The remission rate of Cushing’s disease in patients after neurosurgery varies from 59 to 94%, while the recurrence rate is 3 to 46%. Aim — to evaluate the five-year outcome in neurosurgery patients with Cushing’s disease (CD), depending on preoperative MRI-based identification of pituitary adenoma. Material and methods . The study included 105 neurosurgery patients with histologically confirmed CD. CD remission was confirmed by the development of adrenal insufficiency and/or normalization of serum cortisol and 24-hour urinary free cortisol (24h UFC) levels, as well as by clinical remission. Results . Pituitary adenoma was not visualized by gadolinium MRI in 35 cases. The size of visualized pituitary adenoma varied from 0.3 to 29 mm. After first neurosurgery, remission was achieved in 87 (82.8%) patients. After second neurosurgery, remission occurred in 12 patients. Radiation therapy was conducted in 24 patients. Six patients had bilateral adrenalectomy. Two patients died during remission: one patient died from stroke two years after neurosurgery, and the other patient died due to surgery complications. During five-year follow-up after neurosurgery, remission continued in 76 (72.8%) patients, including 27 (77%) of 35 patients without MRI-detected adenoma and 49 (70%) of 70 patients with MRI-detected pituitary adenoma, p=0.15. Sixty-six patients developed recurrence, and 14 patients had active hypercortisolism. Conclusion . There was no correlation between the rate of preoperative MRI-based detection of pituitary adenoma and the rate of remission in neurosurgery patients with Cushing’s disease during the five year follow-up. The size of pituitary adenoma was a risk factor for adenoma recurrence.

Endogenous hypercortisolism (EH) is a rare endocrine disorder, one of the most frequent manifestations of which is obesity. Due to the high prevalence of the metabolic syndrome and the similarity of the clinical manifestations, EH may remain undiagnosed. However, prompt diagnosis and treatment can effectively promote complete cure of the patient. We describe the clinical case of a patient К., 58 years old, who suffered from morbid obesity, diabetes, uncontrolled hypertension and dyslipidemia. The CT examination revealed bilateral adrenal incidentalomas. The further follow-up let us to establish Cushing's disease. The adrenal tumors in this case may be the results of a long-term stimulation of the adrenal glands by ACTH. There is a possibility that the first manifestation of the disease began at the age of 30 years after the second pregnancy, when she observed weight gain and poorly controlled hypertension. When remission was achieved after neurosurgical treatment, we could observe significant improvements (reduction in body weight of 10 kg, improved glucose levels), but without the full normalization of all complications and symptoms. Conclusion: EH may cause the development of obesity and metabolic syndrome or significantly exacerbate its course. In cases of doubt, weight gain and poorly controlled manifestations of metabolic syndrome screening is justified to exclude EH.

Introduction. The state of pelvic and retroperitoneal lymph nodes is an important prognostic factor for cervical cancer. Lymph node size is the most widely used CT and MR criteria for assessing lymph node status. Lymph nodes measuring more than 1cm in the short axis diameter are considered malignant. However this criterion (nodal size) is not foolproof because of a high percentage of diagnostic errors. The purpose of the study was to develop objective MRI criteria for assessing lymph node metastasis in patients with cervical cancer by measuring the short- and the long-axis diameters of lymph nodes, short axis/long axis ratio (configuration index) and to evaluate their diagnostic value. Materials and methods. The prospective study included 31 patients with histologically confirmed cervical cancer, who underwent radical surgery with standard lymph node dissection. Sixty removed lymph nodes were evaluated. MRI examinations were performed using a 1.5 T scanner in T2- weighted images (T2-WI), T1-WI and T2 weighted sequences with fatty tissue signal suppressing and diffusionweighted MRI. Results. Lymph nodes measuring ≥0.8 cm in the short axis diameter were considered suspicious for metastatic disease. The sensitivity and specificity with a cutoff of ≥0.8cm were 68 % (CI 48.3‑82.9) and 80 % (CI 63.8‑90.3), respectively; the positive and negative predictive values were 71 % and 78 %, respectively; and the accuracy was 75 % (CI 62.7‑84.3). The short axis/long axis ratio (configuration index) of <1.47 indicated a likelihood of pathology in the lymph node. The absence of the hypointense signal from the fatty hilum of lymph nodes was considered as a predictor of lymph node metastasis. The analysis of this criterion showed 80 % sensitivity (CI 60.4‑91.6), 85.7 % specificity (60.4‑91.6), 80 % PPV, 85.1 % NPV and 83.3 % accuracy (CI 60.4‑91.6). Conclusion. Lymph node size of ≥0.8 cm in the short axis diameter and the short axis/long axis ratio (configuration index) of <1.47 appeared to be significant MRI criteria in the assessment of lymph node metastasis. The additional use of MRI criterion such as the absence of the hypointense signal from the fatty hilum of the lymph node made it possible to improve diagnostic accuracy up to 92 % (CI 80.9–97.4).

Rathke’s cleft cyst is one of the causes of hyperprolactinemia. It forms due to pituitary malformation during embryonic period. Nowadays the correct diagnosis still possesses some issues with interpretation of visual data and variable clinical picture. The article presents a clinical case of a patient with Rathke’s cleft cyst that was initially managed as prolactinoma.