Type 1 diabetes: dealing with physical activity.

AIM: For patients with type 1 diabetes (T1D) using multiple insulin injections (MII), there are currently no guidelines for insulin dose adjustments in the event of physical activity (PA) and no simple algorithms that can be applied directly. Thus, the objective of this study was to assess the relevance of simple algorithms based on assessments of PA intensity by T1D patients themselves. METHODS: This 4-month observational study was conducted in 35 patients using the Diabeo software system. Algorithms for insulin dose adjustments aimed to reduce the insulin dose of the meal closest to PA by 30 and 50% for moderate and intense PA, respectively. A 50% reduction plus extra carbohydrates was proposed for intense PA of long duration. These algorithms were entered into the Diabeo system. RESULTS: The mean blood glucose (BG) profile in the event of PA (n = 151 triple BG values) was compared with that when no PA was performed (n = 3606). The initial mean FBG values were similar in both groups (7.58 ± 2.70 mmol/L vs. 7.80 ± 3.49 mmol/L; P = 0.36), whereas there was a slight, but significant, increase in 2-hours postprandial BG (PPBG) values related to PA, with a return to similar values before the next meal. The incidence of mild hypoglycaemia was similar, whether PA was undertaken or not, for the 2-hour PPBG and the next fasting/premeal glucose values. CONCLUSION: This appears to be a pragmatic and efficient method for T1D patients using MII to adjust insulin doses in the event of PA that only requires an assessment of PA intensity by the patients themselves to anticipate the magnitude of the reduction in insulin doses.

Telemedicine and diabetes: achievements and prospects.

Health authorities currently have high expectations for telemedicine (TM), as it addresses several major challenges: to improve access to healthcare (especially for patients in underserved or remote areas); to overcome the scarcity of specialists faced with epidemic disease; and to reduce the costs of healthcare while improving quality. The aims of TM in the field of diabetes differ according to the type of diabetes. In type 1 diabetes (T1DM) associated with complex insulin regimens, the goal of TM is to help patients achieve better control of their blood glucose levels through accurate adjustment of insulin doses. In type 2 diabetes (T2DM), while therapeutic adjustments may be necessary, improvement in blood glucose control is based primarily on behavioural changes (reduced calorie and carbohydrate intakes, increased physical activity). Many TM studies focusing on management of blood glucose levels have been published, but most failed to demonstrate any superiority of TM vs traditional care. While previously published meta-analyses have shown a slight advantage at best for TM, these meta-analyses included a mix of studies of varying durations and different populations (both T1DM and T2DM patients, adults and children), and tested systems of inconsistent quality. Studies published to date on TM suggest two currently promising approaches. First, handheld communicating devices, such as smartphones, loaded with software to apply physicians' prescriptions, have been shown to improve glycaemic control. These systems provide immediate assistance to the patient (such as insulin-dose calculation and food choice optimization at meals), and all data stored in the smartphone can be transmitted to authorized caregivers, enabling remote monitoring and even teleconsultation. These systems, initially developed for T1DM, appear to offer many possibilities for T2DM, too. Second, systems combining an interactive Internet system (or a mobile phone coupled to a remote server) with a system of communication between the healthcare provider and the patient by e-mail, texting or phone calls have also shown certain benefits for glycaemic control. These systems, primarily aimed at T2DM patients, generally provide motivational support as well. Although the individual benefits of these systems for glycaemic control are fewer than with smartphones, their widespread use should be of particular value for overcoming the relative shortage of doctors and reducing the health costs associated with a disease of such epidemic proportions.

Telemedicine: what more is needed for its integration in everyday life?

The Health Authorities have huge expectations of telemedicine (TM): improved patient access to healthcare, a solution to the shortage of doctors in the face of an exponentially expanding disease, and reduced healthcare costs with improved quality. There are a host of applications for TM in the area of diabetes. TM has been validated and has been widely used to screen for diabetic retinopathy, and a number of studies are currently underway for the follow-up of diabetic foot ulcers. However, the main indication of TM remains the follow-up and control of blood glucose. In this area, many studies have been conducted to improve glycaemic control. While most of these studies have failed to show any benefits vs. conventional care, a small number have demonstrated great efficacy of this approach with regard to glycaemia. Using these studies, we attempt to define the key qualities of a successful TM system. How can we extend the results of these experiments beyond the framework of clinical studies and integrate them in daily practice so as to improve diabetes management? This is the key challenge for TM, implementation of which will require reorganization of healthcare, given the evolution of medical demographics. This reorganization will involve healthcare providers specialized in diabetes that may intervene in assigning physicians for especially distressed patients. However, such reorganization will require medico-economic evaluation before it can be implemented on a larger scale.

Real-life application and validation of flexible intensive insulin-therapy algorithms in type 1 diabetes patients.

AIMS: Flexible intensive insulin therapy (FIT) has become the reference standard in type 1 diabetes. Besides carbohydrate counting (CHO), it requires the use of algorithms to adjust prandial insulin doses to the number of CHO portions. As recourse to standard algorithms is usual when initiating FIT, the use of personalized algorithms would also allow more precise adjustments to be made. The aim of the present study was to validate personalized prandial algorithms for FIT as proposed by Howorka et al. in 1990. METHODS: We conducted a 4-month observational study of 35 patients with type 1 diabetes, treated with FIT for at least 6 months, who were already using Howorka's prandial algorithms (meal-related and correctional insulin doses for blood glucose increases induced by CHO). These patients were asked to use a personal digital assistant (PDA) phone with an electronic diary (instead of a paper one) to take advantage of the computerized data-collection system to assess the quality of postprandial metabolic control. RESULTS: Whatever the number of CHO portions, mean postprandial blood glucose values remained close to the target of 7.8mmol/L, and the compensatory algorithm allowed precise correction of preprandial hyperglycaemia. In fact, the algorithms for meal-related and correctional insulin doses at the end of the study did not differ significantly from those initially calculated, but they generally differed from one patient to another. CONCLUSION: In type 1 diabetic patients treated with FIT, the use of individualized parameters permits fast and accurate adjustment of mealtime insulin doses, leading to good control of the postprandial state.

Osteoporotic fractures at presentation of Cushing's disease: two case reports and a literature review.

Osteoporosis is a common complication of Cushing's disease/syndrome. Fractures can be the presenting manifestation. We report two cases and review 28 others from the literature. Clinical, laboratory, and absorptiometry data are reviewed; the vertebrae and ribs were the most common fracture sites, and osteoporosis reversal after treatment varied with age, gender, and symptom duration. The pathophysiology, which remains controversial, is discussed. A search for Cushing's disease/syndrome should be part of the routine evaluation of osteoporosis in children and adults, particularly men.

[Silent ischemic cardiopathy: which diabetics to examine?]. / Cardiopathie ischémique silencieuse: quels diabétiques explorer?

Non-Invasive coronary investigations are positive in 12 to 52% (average 22%) of type II diabetics, and 11 to 30% (average 17%) of type i diabetics. These statistics vary according to bias of recruitment. Haemodynamic lesions are found at coronary angiography in 35 to 80% of patients who have at least one positive non-invasive investigation. Nine to 12% of diabetics have silent myocardial ischaemia (SMI) confirmed by coronary angiography, compared with 1.3 to 5.3% of non-diabetic controls paired for age and sex. The higher frequency of SMI in diabetics seems to be mostly due to the increased frequency of ischaemic heart disease in diabetics. The importance of cardiac autonomic neuropathy (CAN) in SMI is controversial. The risk factors associated with SMI are those usually associated with coronary artery disease: age, masculine gender, hypercholesterolaemia, hypertriglyceridaemia, hypertension, smoking, a family history of cardiovascular disease, insulin therapy (for type II diabetes), proteinuria, retinopathy, peripheral occlusive arterial disease.... The French recommendations for investigating SMI seem to be contradictory. A single risk score in a given patient could help codify the investigation of SMI in diabetics, but this type of score has not yet been validated.

[Tumor and pseudotumor lesions of the adrenal area not to be misdiagnosed]. / Lésions tumorales et pseudo-tumorales de la loge surrénalienne à ne pas méconnaître.

Thirteen patients with a mass in the adrenal gland area discovered at ultrasonography or computed tomography were studied. Hormone levels were normal in all but three patients with adrenal insufficiency. With the exception of three patients with metastatic tumours or adrenal lymphoma, all were operated upon on account of complications or for diagnostic purposes. The pre-operative diagnosis was confirmed by histology in 5 out of 10 cases (tuberculous abscess in 2, cysts in 2 and 1 haematoma in 1 case). In the remaining 5 cases the tentative diagnosis was erroneous: these patients had haematoma, neurofibroma, schwannoma, leiomyosarcoma and angiomyolipoma respectively. Thus, ultrasonography and computed tomography do not always differentiate between adrenal and extra-adrenal masses and between malignancy and non-malignancy; surgical excision therefore seems to be desirable in such cases.

[Insulinoma: diagnostic elements. 13 cases]. / Insulinome: éléments diagnostiques. Treize observations.

The mean age of the 13 patients studied (9 women, 7 men) was 50.5 +/- 15.7 years. The disease was discovered on account of malaise (3 cases), behavioural disorders (4 cases), coma (3 cases), syncope (1 case) or right hemiparesis (1 case) or in the course of systematic examination (1 case). Eleven patients consulted for evaluation of hypoglycaemia and 2 for behavioural disorders. The history was characteristic, with malaise, loss of consciousness, severe neurological disorders (seizures, hemiparesis, hemiplegia or coma) and psychiatric disorders. These symptoms typically occurred in the morning before breakfast or between meals in 9 patients, and atypically at any point of time or after meals in 4 patients. Their hypoglycaemic nature was demonstrated by blood glucose determination in 11/13 cases and by response to ingestion of sugar in 12/13 cases. The mean period elapsed between the initial symptoms and the final diagnosis was 20.3 +/- 17.3 months. Inappropriate insulin secretion was elicited a.m. before breakfast, during Conn's diet or fasting test, or by calculating the blood insulin/glucose ratio or Turner's coefficient. Prior to surgery, the insulinoma was located by ultrasonography in 3/8 cases, by computerized tomography in 2/6 cases, by selective arteriography in 6/11 cases, and by phlebography with spleno-portal catheterization and staged sampling for insulin and C-peptide assays in 8/9 cases. Histological examination after surgery (11 cases) or necropsy (1 case) showed an adenoma without evidence of malignancy.

[Current aspect of Sheehan's syndrome. 20 cases]. / Aspect actuel du syndrome de Sheehan. Vingt observations.

The 20 women investigated were 22 to 59 years old (average 35.9 +/- 2.3 years) when the diagnosis of Sheehan's syndrome was confirmed. Fourteen had had previous pregnancies, 6 were primiparas; average parity was 4. The patients were delivered in hospital, in France, in 14 cases, and abroad (Algeria, Portugal) at home in 6 cases. A history of severe haemorrhage during delivery was recorded in all but 2 cases. This was serious enough to warrant hysterectomy in 2 cases. Agalactia and amenorrhea were observed in all but 1 case in the immediate post-partum period. Transient polyuria and polydipsia occurred in 3 patients. In the months following birth, most women lead restricted lives; they were apathetic, asthenic and indifferent. The diagnosis was established under three different circumstances: in the majority (15/20) on clinical grounds, in 3 cases after acute adrenal failure, in 2 cases, fortuitously. Clinical examination showed signs of global anterior hypophyseal insufficiency involving thyroid, adrenal and gonad stimulating hormones in 14 cases; in 6 cases, the pituitary failure was dissociated. Corticotrophin, somatotropin and prolactin deficiencies were observed in all patients; gonadotrophin (17/20) and thyrotrophin (16/20) deficiencies were common. The diagnosis was confirmed less than 1 month (2 cases) to over 12 years (7 cases) after obstetric haemorrhage (average 6.9 +/- 1.9 years). No correlation was observed between the severity of the syndrome and this time interval. The short term outcome was favourable with return of menstruation and even pregnancy in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mucigenous cysts of the pituitary gland. 3 cases]. / Les kystes mucigènes de l'hypophyse. Trois observations.

Three cases of mucous cysts, or Rathke's cyst, of the pituitary gland are reported. The clinical and biological features were comparable to those of a non-secreting adenoma. Although extremely rare, these cysts must be recognized since their particular and, in theory, specific characteristics (wall made up of a ciliated epithelium with mucus cells and cavity filled with a mucoid substance) distinguish them from other intra or suprasellar pathological formations, especially craniopharyngiomas. The 62 cases reported in the literature suggest that they have a favourable prognosis.

Fertilizing capacity and sperm antibodies in vasovasostomized men.

In order to explain the discrepancy between the patency rate (80%) and the pregnancy rate (46%) in a series of vasovasostomies, attention was focused on a group of patients who became normospermic. The mean age at vasectomy, the duration of vasobstruction, and the parameters of semen analysis were not different for those couples who achieved a pregnancy (n = 8), compared with those couples without pregnancy (n = 7). In the group with pregnancy, six of the eight patients had low titers of serum agglutinins (absent to 1:32), and the fertilizing capacity of their spermatozoa was normal. None had immobilizing antibodies. In the group without pregnancy, six of the seven patients had elevated serum agglutinins (greater than 1:256), and four had agglutinating antibodies in their seminal plasma as well as serum immobilizing antibodies. The spermatozoa of seven patients failed to fertilize zona-free hamster ova. It is concluded that a loss of fertilizing ability of the spermatozoa due to sperm antibodies is an important cause of infertility in vasovasostomized men.

[Adrenocortical scintigraphy with 131I-19-iodocholesterol. Indications and results in 66 cases of hypercortisolism and hyperaldosteronism (author's transl)]. / Scintigraphie cortico-surrénalienne au 131I-19-iodocholestérol. Indications et résultats dans 66 observations d'hypercortisolisme et d'hyperaldostéronisme.

Scintigraphy was used in 66 patients with biochemically demonstrated hyperactivity of the adrenal cortex in order to determine the nature and site of the lesions. In cases of hypercortisolism, uptake was bilateral in 12 patients with Cushing's disease, unilateral in 7 patients with malignant or non-malignant tumours, and absent in 3 cases of large malignant tumours. In cases of hyperaldosteronism, scintigraphy performed during dexamethasone-induced ACTH suppression showed distinctly asymmetrical uptake in 13 patients with Conn's adenoma (confirmed by surgery as being on the good uptake side in 10 patients), symmetrical in 20 patients with biochemical findings indicating bilaterality, and intermediate in 9 patients. There was no false positive diagnosis of tumour. Scintigraphy appears to be of considerable value for locating adrenocortical lesions, especially small tumours.

[Late diagnosis hyperandrogenism due to adrenal enzyme deficiency (author's transl)]. / Hyperandrogénie par déficit enzymatique surrénalien à révélation tardive post-pubertaire.

Six women aged from 17 to 30 years (mean: 21 years) were referred on account disorders which had begun at puberty and had been present for 3 to 15 years. The reasons for consulting were hirsutism in 5 cases and sterility in one. The patients' height (1.61 to 1.70 m; mean: 1.64 m) and weight (54 to 70 kg; mean: 59 kg) were normal. Three women menstruated regularly and 3 had anovular spaniomenorrhaea. Hirsutism with enlargement of the clitoris (Prader's stage I) was apparent in all six cases. Three patients had permanent, though moderate hypertension. The biochemical changes essential to the diagnosis were as follows: 1) in 2 women with 21-hydroxalyse deficiency there was a rise in cortisol precursors (plasma 17-OH progesterone and its urinary metabolite, pregnanetriol). In 4 women with 11-hydroxylase deficiency urinary 17-OH corticosteroids were increased; two had high desoxycorticol levels. A rise in plasma desoxycortisol/cortisol ration under tetracosactrin stimulation is of considerable diagnostic value; 2) plasma androgens (testosterone, delta 4 androstenedione) and their urinary metabolites (17-ketosteroids) were increased; 3) all abnormalities disappeared when the adrenal function was suppressed. Under dexamethasone treatment hirsutism became stabilized or even regressed, blood pressure values rapidly returned to normal, menstrual disorders disappeared and ovular cycles were established. Three women became pregnant and delivered on term.