[Diurnal rhythm of arterial pressure in patients with acromegaly].

24 hr monitoring of arterial pressure (AP) in 46 patients with acromegaly in active phase revealed systolic-diastolic arterial hypertension. Analysis of diurnal profile showed the absence of the normal nocturnal fall in AP (non-dipper profile) and the significant rise in the number of patients with elevated nocturnal AP (night-peakers).

[Neurosyphilis in clinical practice].

Presented is the description of the 41-year-old patient who was delivered to the emergency department of the clinical hospital. The patient has clinical manifestations of the stroke. Intracerebral hematoma of the right cerebral hemisphere was diagnosed on clinical examination. Serosurrey was positive for syphilis. Due to the suspected neurosyphilis, the central laboratory performed additional examination.

[Possibilities for targeted therapy of neuroendocrine tumours].

The treatment of patients with neuroendocrine tumours and hormonally active distant metastases traditionally included surgical removal of the primary neoplasm, embolization of metastases in the liver, therapy with somatostatin analogs and interferon-alpha to prevent excessive production of regulatory peptides (carcinoid and other endocrine syndromes). Patients with neuroendocrine pancreatic tumours were also treated with alkylating chemotherapeutic drugs including streptosocin and temozolomide. The results of such treatment are far from being satisfactory. Recent progress in the treatment of such patients is due to radiotherapy using somatostatin analogs. Moreover, large-scale randomized studies demonstrated the effectiveness of targeted preparations acting on receptors of vascular growth factors and ripamycin target inhibitors ofmammals. Results of the studies on comparative effectiveness of targeted drugs for combined therapy of neuroendocrine tumours are presented.

[The role of insulin resistance in pathogenesis of arterial hypertension].

Arterial hypertension (AH) is a major challenge facing modern medicine. High frequency of AH patients with excess body mass and disturbances ofcarbohydrate metabolism is attributable to their common pathophysiological mechanisms underlain by insulin resistance and resulting compensatory hyperinsulinemia. The authors review modern concepts of AH development in patients with insulin resistance associated with enhanced blood insulin level and increased production of catecholamines playing an important role in AH pathogenesis mediated through sympathetic stimulation of heart, vessels while kidneys. Insulin resistance contributes to AH largely by activating sympathoadrenal system while increased glomerular filtration of glucose is accompanied by its back absorption together with sodium in proximal tubules. It results in hypervolemia and enhanced content of sodium and calcium in vascular walls which leads to their spasm and a rise in the total peripheral vascular tension (TP VT). Insulin promotes fibroblast proliferation and vascular smooth muscle cells via stimulation of tissue growth factors and collagen synthesis in atherosclerotic plaques. The concomitant narrowing of the vessels further increases TPVT. It in turn decreases renal blood flow and thereby activates renin-angiotensin-aldosterone system and development of AH.

[Syphilitic mesaortitis].

A rise in the incidence of latent and late forms of neuro- and visceral syphilis significantly complicates diagnostics of the disease in patients admitted to emergency medicine clinics. Syphilis is believed to be a cause of roughly 0.5% of all cardiopathies. Late syphilitic lesions of the cardiovascular system (cardiovascular syphilis) occur in 0.25-0.96% patients in need of therapeutic treatment, 93.4% of them present with mesaortitis but its life-time diagnosis is possible only in 10% of the cases. Syphilitic lesions in the aorta are especially well apparent at the points of its branching into coronary arteries of the heart and aortic arch. One of the main consequences of syphilitic aortitis is the narrowing of coronary arteries frequently complicated by atherosclerosis, coronary thrombosis, and the resulting myocardial infarction. Another severe complication of syphilitic aortitis is progressive aortic valve insufficiency (in 25-50% of the patients) related to dilatation of the valve ring affected by inflammation. Some patients develop bacterial endocarditis of the aortic valve. Close localization of the coronary artery junction and the aortic valve account for a combination of aortic valve insufficiency and coronary insufficiency in patients with syphilitic process in the initial part of aorta. A case report is presented.

[About the signs of malignant pheochromocytoma].

Morphological criteria for malignant pheochromocytoma remain to be developed According to the WHO recommendations, the sole absolute criteria is the presence of metastases in the organs normally containing no chromaffin tissue. Such signs as cellular and nuclear polymorphism, mytotic activity, vascular invasion, capsular ingrowth are not sufficient to describe a pheochromocytoma as malignant. It is equally dfficult to differentiate between malignant and benign tumours based on histological data since histologically mature neoplasms can produce metastases. Based on the results of original studies, the authors believe that such histological features as vascular and capsular invasion do not necessarily suggest unfavourable prognosis. Therefore, the conclusion of malignancy based on such features can not be regarded as absolute. Probably such neoplasms should be called "pheochromocytomas with morphological signs of malignant growths". They should be referred to the tumours with uncertain malignancy potential based on the known discrepancy between morphological structure and biological activity of neoplasms. Comparative studies of clinical and morphological features of pheochromocytomas showed that their histological type (alveolar; solid, dyscomplexed, trabecular) and morphological signs of malignant growth influence both the clinical picture and arterial hypertension. There are no significant relationship between the above morphological signs, timour mass and clinical manifestations of pheochromocytomas.

[Poorly differentiated stomach adenocarcinoma combined with jejunal stromal tumour. Clinical study].

Gastrointestinal stromal tumours (GIST) first described in 1983 are the commonest mesenchymal neoplsams of the digestive tract. The main pathogenetic mechanism is hypersecretion of tyrosin kinase receptor c-kit (CD-117) by GIST cells and its hyperactivation. A rare clinical case of GIST measuring 1.2 CM with concomitant stomach cancer (poorly differentiated carcinoma) is reported. The tumours were discovered intraoperatively. To our knowledge, data on such cases are practically lacking in the literature.

[Clinical features of chronic obstructive pulmonary disease course in persons who underwent radiation impact].

Experience of 10-years observation of 164 patients who underwent radiation impact, 38 (23%) afterwards had chronic obstructive pulmonary disease (COPD), is analyzed in the article. It is demonstrated, that timely COPD diagnostics must be based on thorough gathering of anamnestic data, analysis of clinical manifestations and results of annual examination of pulmonary ventilation function. Changes in time of COPD clinical symptoms among COPD patients who underwent radiation influence are considered. It was established, that in patients who underwent radiation influence, COPD began in younger age, coursed more severe, with more frequent aggravations, requiring inpatient treatment. Therapy of this category of persons required all drugs used at COPD treatment.

[The prevalence of initial stages of coronary artery disease in relation to risk factors in military men of dangerous professions].

Coronary artery disease (CAD) remains the leading cause of death in most highly developed countries. According to the WHO, more than 17 million people in the world die of cardiovascular pathology (CVP) annually; of them, more than seven million die of CAD. For the medical service of Russian Federation Armed Forces, CAD and atherosclerosis present an important problem due to their prevalence in military men leading to high levels of morbidity, mortality, labor losses, disability, dismiss rate and disqualification of highly professional officers and generals. Certain factors of military service and extreme factors have been found to increase CAD risk. Until now, the incidence and prevalence of initial forms of CAD in military men of dangerous professions have been studied insufficiently. In order to investigate the prevalence of atherosclerotic cardiosclerosis (ASCS), the effects of risk factors (RF), and prognostication of its development, 267 military men, including 14 men of dangerous professions (pilots, navigators, command post operators), and 153 engineers, technicians and supply officers were examined at Military Hospital No7, Mandryk Military Hospital No 2, and four units of a Space Forces division. The clinico-functional examination revealed ASCS in 53 or 19.8% of the servicemen; its rate increased with age. Only a few cases of ASCS were found in subjects aged less than 30 years; a significant increase in ASCS frequency was noted in 41- to 50-year-old subjects (29.8%); between 51 and 60 years old ASCS was found in 32% of the subjects, which meant only a 2.2% increase vs. the previous age group. Possibly, this could be connected with the fact that at this age initial signs of initial forms of CAD, including ASCS in military men of dangerous professions depended not only on age, conventional RF of CAD, but on occupational hazardous factors as well. Lipid exchange disorder is an important RF for the development and progress of various CVP, CAD in the first place. Timely and correct diagnostics and interpretation of an altered lipid profile as well as assessment of concomitant cardiovascular RF are necessary conditions to organize rational prophylaxis of the most important CVP.

[A case of pancreatic glucagonoma].

Neuroendocrine tumor consisting of pancreatic alpha-cells -- glucagonoma -- is a very rare finding (one case per two million people a year). This functionally active, usually malignant tumor has typical clinical manifestations. Glucagonoma syndrome is a disease that has an original clinical picture that includes necrolytic migrating erythema with secondary bullous dermatitis, glucose tolerance disorder or diabetes mellitus, weight loss, anemia, hypoaminoacidemia, venous thrombosis, and alimentary and mental disturbances. By the time diagnosis is made, 60 to 70% of glucagonomas already give metastases, and even small glucagonomas should be considered tumors with unknown malignant potential or malignant tumors. Glucagonomas grow slowly, and patients live long (the survival median is approximately 15 years). The authors describe their own observation.

[Connective tissue dysplasias (hereditary collagenopathies)].

Connective tissue dysplasia (hereditary collagenopathy) presents a group of genetically heterogenous and clinically polymorphic pathological conditions, associated with disturbances in the forming of connective tissue during the embryonal and postnatal periods. Differentiated dysplasias include monofactor diseases with an established genetic defect and clear clinical symptoms, such as Marfan's syndrome, Ehlers-Danlo's syndrome, and osteogenesis imperfecta. The variants of non-differentiated hereditary dysplasias include primary mitral valve prolapse and other minor heart anomalies, tracheobronchial dyskinesia, visceroptosis, join hypermobility, congenital chest deformations, "weakness" of the ligamentous apparatus of the foot and the spine, and a range of other prevalent pathological changes. The author adduces his own observation of a patient with Marfan's syndrome.

[Somatostatin analogues in treatment of gastrointestinal and pancreatic neuroendocrine tumors].

Clinical application of natural somatostatin is limited due to its short effect (the half-life of the preparation is less than 3 min), and a rebound effect after its administration. For these reasons, synthetic analogues of somatostatin, among which sandostatin (octreotide acetate) was the first one, were developed. Other cyclic analogues with similar sensitivity and activity profile, such as lanreotide (somatulin), somatostatin-14, and SOM 230, have been developed as well. These preparations seem to possess certain antiproliferative activity. Somatostatin analogues may be administered in repeated hypodermic injections, or repeated or prolonged intravenous infusions. Long-acting intramuscular preparations (sandostatin LAR) are usually administered once in four weeks, while long-acting lanreotide (somatulin) is administered once in two weeks. Sandostatin therapy is indicated to patients with functionally active neuroendocrine tumors of the stomach, duodenum, small bowel, or appendix. Glucagonomas, vipomas, and, to a lesser degree, gastrinomas and metastatic insulinomas are examples of functionally active endocrine pancreatic tumors that should be treated with sandostatin. Patients are selected according to a positive result of OcreoScan test. Other syndromes, which should be treated with octreotide, include ectopic secretion of adrenocorticotropic hormone in Cushing syndrome, oncogenic osteomalacia, and hypercalciemia resulting from ectopic secretion of parathyroid-like peptide. In patients with an advanced carcinoid syndrome, the starting dose of sandostatin (ocreotide) is 150 mcgr administered three times a day in hypordermic injections during 10 to 14 days, after which sandostatin LAR is administered in a dose of 20 mg once a month. Sandostatin is usually administered for the life-term of the patient, exept cases of intractable adverse effects or the development of total insensitivity.

[A rare case of large-cell gastric lymphoma in a patient with chronic lympholeucosis].

Chronic lympholeucosis (CLL) is a B-cell lymphoproliferative disease, the morphological substrate of which is a clone of lymphocytes similar in size and morphology to normal mature lymphocyte and similar in immunophenotype to B lymphocytes at late stages of differentiation. The occurrence of large-cell lymphoma against the background of B-CLL is called Richter syndrome. A new tumor may occur in lymph nodes, the spleen, the liver, and the gastrointestinal tract (GIT). GIT involvement in Richter syndrome is a very rare case; the authors found only six descriptions of such cases in available literature, and no such description in Russian literature. The authors adduce their own observation.