D. Koev
 

Hitherto criteria for diagnosing diabetes mellitus are based on the 1985 consensus reached by a WHO expert committee. In late 1997, the American Diabetes Association (ADA) announced and published new diagnostic criteria for diabetes mellitus. The main changes proposed include: 1. A decrease in the diagnostic fasting glycemia margin from 6,7 to 6,1 mmol/l for capillary blood (below 7,0 for venous blood); 2. Identification of a new clinical group Г persons presenting impaired fasting glicemia in the range 5,6 to 6,1 mmol/l; 3. Recommendation to discard routine clinical application of the oral glucose tolerance test (OGTT), and instead to use fasting blood glucose only; 4. Two abnormal results are needed to diagnose diabetes in patients free of two major symptoms of the disease.

The reasons for such changes are both practical and theoretical, and are directly linked to glycemia level giving rise to vascular complications. The new criteria will alter the overall incidence of diabetes in the population. However, as shown by the results fasting blood glucose and glycemia at  120 minutes of OGTT are associated to different pathogenetic mechanisms of glucose tolerance inhibition, and have different diagnostic value in the various population  groups. OGTT results are a better predictor of further diabetes mellitus development, in comparison with fasting glicemia. To cover all persons in the earliest stage of diabetes mellitus type 2 with a view to institute early treatment and prophylaxis against vascular damage, it is advisable to proceed with using OGTT along with mass fasting glycemia in diagnosing diabetes.

Keywords: diabetes mellitus, diagnostic criteria, fasting glycemia, OGTT.

S. Hubaveshki, Ph. Kumanov
 

Along with the characteristic features of hypo- and hyperthyroidism, a broad spectrum of abnormal sexual development disorders are also noted. Special attention is focused on the constellation hypothyroidism and a rare form of pseudopuberty. Usually, hypothyroidism in childhren is associated mainly with growth impairment and retardation of bone and sexual maturation. In some adolescents juvenile hypothyroidism may produce a state of macrogonadism and partial (pseudo-) puberty. Growth retardation is one of the basic signs of hypothyroidism in childhood.  Most comprehensive follow-up studies in boys demonstrate that prepubertal thyroid failure may occur in conjunction with pseudopuberty. The clinical picture is characterized by enlargement of testes, without virilization. Testis specimens obtained prior to puberty show tubular compartment predominance, characterized by early onset of spermatogenesis with few spermatocytes and spermatids, but no increase in Leydigњs cells count. On the contrary, biopsies taken from adult patients with untreated juvenile-onset hypothyroidism reveal tubular walls with fibrosis and hyalinization, fibroblastic proliferation, peritubular and interstitial fibrosis, and sparse Leydig cells. The histological finding is rather outlined by testicular atrophy and involution, pointing to the necessity of a normal thyroid hormone milieu in the perinatal period for normal testicular development. 

Keywords: thyroid hormones, hypothyroidism, puberty, gonads and macrogonadism.
 

M. Pavlova, S. Simeonov, S. Tsvetkova, L. Mincheva, R. Dimitrova, D. Troev, E. Enchev, N. Botoushanov, I. Iliev, M. Mitkov
 

This is a report on the effect of treating 16 women (mean age 51,6 years) with postmenopausal osteoporosis over a one-year period, using intermittent iv administration of pamidronate (Aredia) at dose 30 mg every 3 months. Baseline therapy with 1 g calcium and 1000 IU vitamin D on a daily basis is carried out in all of them. Bone mineral content (BMC) of lumbal vertebrae is measured by CT densitometry in the beginning of study, and at 6 and 12 months, respectively. All patients have initial BMC values below fracture threshold, and below the age and sex matched normal reference BMC values, averaging 52,3 per cent. At 6 months, mean 3,3% increase, and at 12 months Г mean 6,7% increase in BMC relative to the initial values is registered. Serum levels of total and ionized calcium, phosphorus, alkaline phosphatase and 24-hour urine excretion are also measured. The dynamics of intact PTH, osteocalcine and AP levels are monitored throughout the first 3 months of treatment. In all patients there is a substantial relief of symptoms, with no fractures sustained by the end of the one-year period.

In conclusion, it is stressed that pamidronate is a reliable drug and prospective alternative in postmenopausal osteoporosis treatment.

Keywords: osteoporosis, bone mineral content, bisphosphonates-pamidronate, parathormone, osteocalcin.
 

M. Atanassova, A. Protopopova, L. Koeva, I. Kotzev,  A. Klisarova, L. Svrakova
 

Motility disorders in the gastrointestinal tract, esophagus in particular, developing against the background of diabetic vegetopathy, are still not well enough clarified. It is the purpose of the work to establish the frequency and character of esophageal pathology in diabetes type 1 (D) patients, and seek for a correlation between ascertaind esophageal pathology and peripheral polyneuropathy, and between esophageal pathology and blood glucose levels. The study covers 27 D patients Г 15 with and 12 without signs of polyneuropathy. The diagnostic procedures used include: past history based on standartized questionnaire, fibro-esophago-gastroduodenoscopy, punch and brush biopsy for routine histo- and cytomorphological evaluation + Candida and Helicobacter pylori (HP) screening, dynamic scintigraphy with 99mTc pertechnetate for tracing liquid bolus evacuation, neurological evacuation + electromyography for judging polyneuropathy coexistence. Labs: blood glucose profile, ionogram, HBA1c. 

Results: Esophageal pathology is ascertained by endoscopy and biopsy material examination in 20 patients (74%). In 66,6 per cent it is closely related to GERD. Candida albicans esophagitis is diagnosed in 2 instances (7,4%). No evidence of HP infection in esophageal mucosa is found. Scintigraphy is performed in 8 cases, and in 5 (62,5%) it reveals prolonged esophageal transport function. In the polyneuropathy group esophageal pathology is diagnosed in 80% vs 66% in the group free of polyneuropathy. Esophagitis grade IIГIV is noted in 3 patients with newly discovered D free of polyneuropathy, and in two with polyneuropathy and D duration < 5 years. In patients with esophageal pathology fasting blood glucose levels amount to 11,5?2 versus 14,9?2,5 postprandial. HBA1c is 10,3?2,1. Twenty-five percent of patients with esophageal pathology are free of symptoms pointing to digestive tract disorders, while 20 percent present such symptoms although atypical.

Conclusions: GERD with or without esophagitis is the commonest esophageal pathology in D type 1; GERD symptoms are equivocal or altogether absent in 25% of patients. Atypical symptoms, such as chronic cough and noncardiac chest pain, are observed in 10 to 20% of patients. There is no correlation between esophageal pathology, on the one hand, and duration of D type 1 and polyneuropathy symptomatology, on the other. Esophageal pathology in D type 1 correlates strongly with blood glucose control.

Keywords: diabetes, esophageal pathology, GERD, polyneuropathy, blood glucose.
 

V. Todorov, A. Tomova, S. Maximova
 

This is a report on eighteen female patients presenting anorexia nervosa. A number of anthropological parameters and indices relating to the disorder are assayed. The results show significantly lower values of the indicators chest measurement, weight and BMI, as compared to age-matched healthy women (p<0,001). The stature and bihumeral diameter in patients are significantly, higher but the ratio between the two indicators is equal to that in controls. A markedly expressed leptosome constitution is documented.

Comparative assessment of data on hormonal levels demonstrate a decrease in gonadotropic hormones (LH, FSH) and estradiol, giving rise to hypogonadotropic hypogonadism in females with anorexia nervosa.

Keywords: anorexia nervosa, anthropometric parameters, hypogonadotropic hypogonadism.
 

E. Karahanian, N. Kaleva, T. Shabanova, Hr. Dimitrov
 

The functional state of the thyroid gland is studied in 53 children and teenagers, aged 6 to 18 years, presenting Hashimotoњs thyroiditis. Upon discovering the disease and throughout its 5-year evolution, examinations are performed as follows: ultrasonography and scintigraphy of the thyroid, serum antibody levels (TAT, MAT), thyroid hormones (T3, T4), thyrotropin (TSH) and needle aspiration biopsy (AB). Analysis of the results shows thyroid gland hyperplasia I to III grade, high titer antithyroid antibodies and different serum concentrations of thyroid and thyrotropic hormones. Thirty-three patients (62%) are euthyroid, 8 (15%) Г hyperthyroid, 2 (4%) Г with clinically expressed hypothyroidism, and 10 (19%) Г with subclinical hypothyroidism. At termination of the study, hyperfunction of the gland returns to normal, but in the patients of group three hypothyroidism persists. In the group of euthyroid patients normal function is regained in 28 cases, while in the remainder (5) subclinical hypothyroidism is present. Two children with subclinical hypothyroidism run a favourable course of evolution. In the latter permanent normalization of TSH level is attained within 6 months of treatment with thyroid hormones.

The inference is reached that in pediatric age the functional state of thyroidea against the background of Hashimotoњs thyroiditis is characterized by diversity and frequent fluctuations, and therefore constant monitoring by pediatrician-endocrinologist, as well as undertaking opportune treatment in case of gland dysfunction evidence are mandatory.

Keywords: autoimmune thyroiditis, thyroid hyperfunction, thyroid hyperfunction, thyroid hypofunction.
 

Ph. Kumanov, A. Tomova, P. Karanova, O. Brancov
 

A case of androgen insensitivity syndrome (AIS), rarely met with in clinical practice, is described and comprehensively discussed. It concerns a 16Гyear-old girl presenting primary amenorrhea,  a blind ending vagina, male karyotype (46,XY) and histologically documented bilateral testicular tissue, lacking spermatogenic cells. In the course of study, androgen insensitivity is confirmed by paradoxical reaction of the sex hormone binding globulin (SHBG), following repeated (two-fold) depot-testosterone administration (x 250 mg Sustanon within 20 days). 

The specificity of clinical course and analysis of the cytogenetic and histological data contribute to gain better understanding of the syndrome. 

Keywords: androgen receptor, androgen insensitivity, testosterone, sex hormone binding globulin.