VITILIGO30 AQUIRED THYROID PATOLOGY MOSTLY THYROIDITIS HASHIMOTO AUTOIMMUNE

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 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 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% before 40 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 • T 3 high t 4 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 t 4 t 3

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 B 12 def anemia Elthroxin-dexa Cabg-chf-severe cihd-not replacement of elthroxin • •

Diabetes insipidus Plasma osmolarity more 290—adh secretion— sensitivity H 2 O --reabsorbtion of water 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 • •

Metabolic syndrom x-syndrom Fg>110 Abdominal obesiry -10288 Tg>150 hdl<40 htn >13085 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 A 1 C 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 A 1 C in standard group 8. 4% • Median Hb A 1 C 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

GPP 4 – энзим ди пептидил пептидаза 4 разрушает GLP 1 GPP 4 inhibitor – sitagliptin- Januvia • Таблетки 25, 50, 100 мг И 50 мг при почечной недостаточности 25 Metformin + Januvia = Januet Metformin 500/50 , 850/50 , 1000/50