24VITILIGO VERSUS

HYPERPIGMENTATION

VITILIGO-30% AQUIREDTHYROID PATOLOGY MOSTLY THYROIDITIS HASHIMOTO

AUTOIMMUNE DISEASE-DM PERNICIOUS ANEMIA

ADDISON DISEASE- HYPERPIGMENTATION

25DM-BP

BP-120/80ACE

TARGET-CHF CRF

26•Hypercalcemia+malignancy•80%-MTS-bone destruction•20%-PTH like substation•Most-ca of breast lung renal•MM-lytic mts-hypercalcemia•Most-paraneoplastyc syndrom•Secondary hyperparathyroidism-

hypocalcemia-hypephosphatemia-high pth

27•No family history of graves or hashimoto for ca of

thyroid•Solid nodules more malignant than cystyc•Nodule hyperactive non malignant•70% pappilary cancer 15% follicular cancer 5%

anaplastic 5% lymphoma•Medullary carcinoma-0,5%•Men 2-medullary cancer+pheochromacytoma Men 1-

hyperparahyroidism+prolactinoma+glucagonoma•Calcitonin-marker of thyroid cancer threatment

Dopamine lower prolactine level28

•Bromocriptin/dopamine agonist/ for microadenoma threatment

•Neuroleptics = high prolactine•Only high doses of estrogen=high prolactine•Microadenoma less 1 sm macroadenoma

more then 1 sm•Threatment-

bromocriptine’surgery’radiotherapy’pergolide

Hyperthyroidism

•More female•Graves d.-most common 90% before40•Ophtalmopathy,pretibial mixedema after

therapy,vitiligo,gynecomasty,onycholysis•thyroid enlarged +bruits•Reversible cardiomyopathy•Toxic multinodular goiter-elderly,long standing

goiter,cardiovascular symptoms,weight loss,constipation,

HYPERTHYROIDISM

•Single hot-toxic nodule•T3 high t4 high,threatment elthroxin anr then surgery•Transient hyperthyroidism-subacute or

After viral infection esr high ,zahvat joda nizkij-Lymphatyc

Hashimoto-female middle age antiperoxidase abSubacute pospartum thyroidit –transient.mild,like

hashimoto Subclinical hyperthyroidism-low tsh normal t4 t3

Hypethyroidism

•Goiterogenic medications-jod contrast,amiodaron,lithium

•Diagnostic-thyroid scan•Lab-hypercalcemia,anemia,lymphocytosis,GOT GPT high•Treatment-bb ,methimasol,ptu•Methimasol-agranulocitosis•Elderly-ablation with radioactive jod,young-surgery•Side effects-hypothyroidism,laryngeoparalysis•Treatment of oftalmopathy-high doses iv steroids

hypothyroidism

•Female,most hashimoto ,primary –thyroid function secondary-hypophisis function

•Severe-mixedema+cts+amenorrhea+hypotension•Hdl-decrease ldl-increase•Anemia normo-normo•B12 def anemia•Elthroxin-dexa•Cabg-chf-severe cihd-not replacement of elthroxin

Diabetes insipidus

•Plasma osmolarity more 290—adh secretion— reabsorbtion of water rise--sensitivity H2O

•rise in distal canals•Water diuresis/di/ versus solution

diuresis/dm/•Water diuresis-low osmolarity of urine•Nephrogenic di-lithium or amphotericin• Di-high osmolarity of plasma

Addison disease

•Primary adrenocortical insufficiency•100%weakness,weight loss,hypotonia,•Na low k high bun high ca high acth high•Hyperpigmentation•Causes-tb cancer •Therapy if acute-iv hydrocortison

Conn’s syndrom

•Primary hyperaldosteronism•Mineralcorticoids excess•Weakness•Hypertension•Adenoma or hyperplasia•Na high k low renin low •High kalium in urine•Treatment-surgery ,spironolactone

hypoglycemia

•Whipple triade-glucose low 50 +neuroglycopenia/confusion,letargy,blurred vision/

+adrenogenic stimulation-anxiety,sweating,palpitation/+symptoms dissapearance

with glucose level Normalization

Thrue reactive hypoglycemia-after gastric surgery-not demping syndrome

Non-isled cell tumors-hepatoma-insulin low c-peptide lowInsulinoma-insuline high c-peptide high

DM•DCCT-DIABETES CONTROL AND DIABETES COMPLICATION

STUDY-TYPE 1-GLUCOSE CONTROLE LOWER MICROVASCULAR COMLICATIONS

•UKPDS-UNATED KINGDOM PROSPECTIVE DIABETES STUDY GLUCOSE CONTROLE LOWER NEPHROPATHY AND

RETINOPATHY•IGT -5% EVERY EAR-DM•DRUGS-THIAZIDES BB ZYPREXA•A-MIMETICS•FENITOIN•LADA-LATE AUTOIMUNE DIABETES OF ADULTS-AB TO INSULIN

Risk factors for dm

•Недостаточность упражнений•Этнические –азиаты.эфиопы•Вес при рождении более 4 кг•Igt ifg•Pregnancy diabetes•Pco•Htn •Hdl<35 tg>250

Metabolic syndromx-syndrom

•Fg>110•Abdominal obesiry -102\88•Tg>150•hdl<40•htn >130\85•3 criterions

ACCORD –Action of Control Cardiovascular Risk in DM

•No significant decrease in cardiovascular events with intensive glucose control

•Trial ended after 3.5 years because of significant increase in death in intensive

glucose control group

ADVANCE –Action in Diabetes and vascular disease

•Published 12.06.08 NEJ of Medicine•11. 400 patients with DM type 2•There was no evidence that intensive glucose

control reduce new retinopathy ,nephropathy,polyneuropathy or

risk of major cardiovascular events

Reduce Hb A1C to 1%

•Microvascular complication reduce to 37%• MI risk less 14%•All diabetes related complications 21%•Amputation 47%

VADT INVESTIGATION- vascular complications in Veteran with type 2 DM

•Median Hb A1C in standard group 8.4%•Median Hb A1C in intensive group 6.9%•1791 military veterans•Median follow up 5.6 years•No significant difference in retinopathy,

neuropathy, nephropathy and major cardiovascular events

Сульфонуреа

•Глибенкламид – Глюбен - 5 мг•Глипизид - Глюко Райт – 5 мг•Глимеперид – Амарил -1, 2. 3 мг

Бигуанид

•Глюкофаж, Мерформин,Глюфор 850мг

Репаглинид

•Новонорм 0.5, 1, 2 мг

Инкретины

•GLP 1- Glucagon Like Peptide выделяетсяВ тонком кишечнике Л клетками и стимулирует

выброс инсулина на пищу-Подавляет секрецию глюкагона-Замедляет опорожнение желудка-Вызывает чувство сытости , меньше

потребность в пище-уменьшает апоптоз в бета клетках

Баета – эксенатид и Виктоза-липаглутид

•Иньекции баеты дважды в деньПервый месяц 5 мг дважды в день

и далее по 10 мгПерерыв между первым и вторым уколом не

менее 6 часов -Виктоза 6 мг – раз в день

GPP4 – энзим ди пептидил пептидаза 4 разрушает GLP 1

•GPP4 inhibitor – sitagliptin- Januvia Таблетки 25, 50, 100 мг

25И 50 мг при почечной недостаточности-Metformin + Januvia = Januet

Metformin500/50 , 850/50 , 1000/50

Розиглитазоны и пиоглитазоны

•Авандия, Россини 4, 8 мг –розиглитазон•Новопиоглитазон