VITILIGO-30% AQUIRED THYROID PATOLOGY MOSTLY THYROIDITIS HASHIMOTO
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VITILIGO-30% AQUIRED THYROID PATOLOGY MOSTLY THYROIDITIS HASHIMOTO AUTOIMMUNE DISEASE-DM PERNICIOUS ANEMIA 24 VITILIGO VERSUS HYPERPIGMENTATION ADDISON DISEASE- HYPERPIGMENTATION 25 DM-BP BP-120/80 ACE 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 hyperparathyroidismhypocalcemia-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 1hyperparahyroidism+prolactinoma+glucagonoma Calcitonin-marker of thyroid cancer threatment • • • • • • • Dopamine lower prolactine level 28 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 Threatmentbromocriptine’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 ab Subacute 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— sensitivity H2O --reabsorbtion of water rise 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 stimulationanxiety,sweating,palpitation/+symptoms dissapearance with glucose level Normalization Thrue reactive hypoglycemia-after gastric surgerynot demping syndrome Non-isled cell tumors-hepatoma-insulin low cpeptide low Insulinoma-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 syndrom x-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 выделяется • В 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 день • Первый месяц 5 мг дважды в день и далее по 10 мг Перерыв 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 И 50 мг при почечной недостаточности 25 Metformin + Januvia = Januet Metformin500/50 , 850/50 , 1000/50 Розиглитазоны и пиоглитазоны Авандия, Россини 4, 8 мг –розиглитазон • Новопиоглитазон •
