Screening for deprivation using the EPICES score: a tool for detecting patients at high risk of diabetic complications and poor quality of life.

AIM: Deprivation has been linked to more complicated and uncontrolled diabetes. The validated Évaluation de la précarité et des inégalités de santé dans les centres d'examens de santé (EPICES; Evaluation of the Deprivation and Inequalities of Health in Healthcare Centres) score could help to identify such deprived patients. The present study evaluated the relationships between deprivation and prevalence of complications, uncontrolled diabetes and quality of life. METHODS: This prospective study was conducted in the diabetology department of a tertiary university hospital from November 2006 to July 2007. Patients with diabetes were divided into two groups, according to their deprivation status [non-deprived: EPICES score<30.17; deprived: EPICES score≥30.17 (56.5%)]. Diabetes control, complications and quality of life [Short Form Health Survey (SF-36)] were compared in the two groups. RESULTS: Of a total of 102 patients, 97 completed all of the questionnaires: 18 had type 1 diabetes and 79 had type 2 diabetes, in a geographical area moderately affected by deprivation. No statistical relationship could be demonstrated between deprivation and HbA(1c). Deprived patients with diabetes presented with higher levels of fasting blood glucose, lower levels of LDL cholesterol and a significantly higher risk of obesity (P=0.0020). As for complications, microalbuminuria was linked to deprivation (P=0.03), but no associations with other complications were found. Quality of life was poorer for all physical, mental and social dimensions in deprived patients. CONCLUSION: In this diabetic population, deprivation and glycaemic control were not associated. However, more deprived subjects with diabetes were at higher risk of renal disease. A deprived state was related to an altered quality of life as assessed by the SF-36 score.

Epidemiology, clinical presentation, treatment and prognosis of a regional series of 26 anaplastic thyroid carcinomas (ATC). Comparison with the literature.

OBJECTIVE: The aim of this study is to retrospectively describe the epidemiological and clinical features, therapeutic modalities, prognostic factors and survival figures in a population of patients with anaplastic thyroid carcinoma (ATC) observed in Auvergne, France. We compared these data with those in the literature. MATERIAL AND METHODS: The analysis was conducted based on a computer database containing a regional register recorded by health professionals treating ATC. RESULTS: Of the 1500 cancers observed over 16 years, 26 were identified as ATC. The male/female ratio was 1/2.7 and the average age: 72.1; 76.9% of the cases had thyroid medical history, average tumor size at diagnosis was 7.35 cm with N1 in the course of illness in 61.5% of cases, M1 in 34.6% of cases. Surgery was performed in 84.6% of cases, radiotherapy in 53.8% and chemotherapy in 19.2%. The average survival was 9 months, the survival median: 4 months. CONCLUSION: Our results show that, in univariate analysis, age above 75, capsular invasion, lymph nodes metastasis, tumor residue after surgery and lack of multimodal treatment (particularly radiotherapy in patients without tumor residue) are factors of poor prognosis. In a multivariate analysis only age above 75, followed by node invasion, capsular invasion, and finally female gender are factors of poor prognosis.

Spontaneous rupture of Achilles tendon and Cushing's disease. Case report.

Spontaneous rupture of Achilles tendon is observed in patients with tumors, metabolic disorders, infections and systemic diseases. Fluoroquinolones may cause tendinopathies. In addition, spontaneous rupture uncommonly occurs in Cushing's syndrome. We report a case of Cushing's disease revealed by recurrent rupture of Achilles tendon. Tendon tears are described in patients receiving long-term steroid treatment, probably via a mechanism similar to that one occurring in Cushing's syndrome. Although exceptional, this diagnosis should be discussed in patients with spontaneous rupture of Achilles tendon.

Embolization of hepatic and adrenal metastasis to treat Cushing's syndrome associated with medullary thyroid carcinoma: a case report.

We report functionally successful hepatic and left adrenal embolization with particles to treat Cushing's syndrome associated with a medullary thyroid carcinoma.

[Steroid responsive encephalopathy associated with auto-immune thyroiditis]. / Encéphalopathie corticosensible associée à une thyroidite auto-immune: données actuelles.

Since the first description of encephalopathy associated with Hashimoto's thyroiditis in 1966, more than 100 cases of this entity called Hashimoto's encephalopathy or SREAT [steroid-responsive encephalopathy associated with auto-immune thyroiditis] have been reported. The two cases reported here illustrate different diagnostic criteria and offer the opportunity to discuss the many pathophysiological hypotheses based on particularly pertinent biological data, especially the activity of anti-TPO and anti-TG antibodies present in serum and cerebrospinal fluid and the recent discovery of anti-alpha-enolase antibody. Different treatment options are also discussed, in particular corticosteroid therapy.

Response of glucose disposal to hyperinsulinaemia in human hypothyroidism and hyperthyroidism.

We have examined insulin action on glucose metabolism in six hypothyroid patients before and after regular thyroid hormone treatment, and in six healthy volunteers before and after transient induction of moderate hyperthyroidism. Insulin was infused under euglycaemic and eukalaemic clamps. An appropriate amino acid infusion was used to blunt insulin-induced decreases in amino acid levels. Glucose kinetics were assessed using a primed continuous infusion of [6,6-(2)H(2)]glucose. The results showed that basal plasma insulin and glucose levels (i.e. before infusion) were similar in each case. Despite similar insulin infusion rates, the plateau value of insulin was lower after thyroid treatment in both hypothyroid patients and healthy volunteers. The rate of exogenous glucose needed to maintain plasma glucose at a steady-state level was increased by thyroid hormone in hypothyroid patients (P <0.05), but not in healthy volunteers. Thyroid treatment resulted in a significant increase in basal glucose disposal in both groups (P <0.05). Insulin, in conjunction with glucose and amino acids, significantly stimulated glucose disposal (P <0.05) under all conditions. The incremental increase in glucose disposal after infusion tended to be higher following thyroid hormone treatment, but this was not statistically significant. However, the ratio of the incremental increase in glucose disposal to the increase in plasma insulin was significantly improved after thyroid hormone treatment in hypothyroid patients (P <0.05). It was also increased in healthy volunteers, but not significantly. We conclude that thyroid hormones improve the ability of insulin to stimulate glucose disposal related to insulinaemia. This phenomenon may be highly sensitive, because it was only apparent at low thyroid hormone levels.

Divergence in plasmatic and urinary isoprostane levels in type 2 diabetes.

BACKGROUND: Oxidative stress is currently suggested as a mechanism underlying diabetes. The present study was designed to evaluate isoprostane levels in plasma and in urine in type 2 diabetic patients, and to compare them to other currently used biomarkers of oxidative stress. METHODS: The work was performed in a control group (n = 10) and in a type 2 diabetic group (n = 10). Besides the traditional biochemical parameters, we evaluated the plasma and urine levels of isoprostanes and malondialdehyde (MDA) as markers of oxidative stress. RESULTS: We found increased plasma and urine MDA in the diabetic patients and almost significantly decreased plasma vitamin E. Urinary isoprostane levels in diabetic patients were increased but they presented a strong tendency to a decrease in plasma isoprostanes. It is therefore suggested that, in the studied diabetic patients, although the production of isoprostanes in the body was increased (as other plasma oxidative stress biomarkers were altered) it did not lead to an increase in plasma isoprostane levels. It could be hypothesised that this results from an increased elimination of this metabolite and therefore an increased excretion in urine. CONCLUSION: Our results showed that the measurement of same oxidative stress biomarker, isoprostane, in two different biologic fluids, plasma and urine, led to divergent results and emphasised the importance to measure a biomarker both in the circulation fluid (plasma) and in the elimination fluid (urine), to have a general idea of what is occurring in the organism.

[Primary hypothyroidism in the adult older than 60 years. Characteristics and follow-up after initiation of replacement treatment in hospital]. / Hypothyroïdie primaire de l'adulte de plus de 60 ans. Caractéristiques et suivi après initiation du traitement substitutif en milieu hospitalier.

OBJECTIVE: Primary hypothyroidism is common in the elderly. Yet its care remains unclear. PATIENTS AND METHODS: Clinical, biological characteristics and outcome of 45 patients aged over 60 years admitted for in-hospital initiation of treatment for primary hypothyroidism were recorded. Causes and tolerance of treatment (clinical and ECG monitoring in hospital) were seek for. RESULTS: Initial symptoms, predominantly fatigue (84.4%), were moderate, contrasting with severe biological hormonal deficiency. The most common routine biological change was hypercholesterolemia (57.6%). Female predominance was obvious (77.8%) and the most usual aetiology autoimmune chronic thyroiditis. Despite variability of symptoms, long term follow-up demonstrates a positive response to treatment, including an improvement in fatigue, eye-lid swelling, bradycardia and overweight. This clinical improvement was achieved on an average dose of 1.22 +/- 0.47 mg/kg/day L-T4 in order to maintain normal TSH (3.76 +/- 2.93 mUI/l). Cardiovascular incidents while starting treatment require experienced care and low dose initial treatment. CONCLUSION: Primary hypothyroidism is still lately discovered in the elderly. Yet, since treatment is efficacious and simple, the disease should be searched for and cared after whenever a related symptom occurs.

[Pituitary gland MRI and Cushing disease: report of 14 operated patients]. / IRM hypophysaire et maladie de Cushing: à propos de 14 patients opérés.

PURPOSE: Evaluate the MR sensibility for detection and localisation of ACTH-secreting microadenomas of the pituitary gland. PATIENTS: and method. The MRI studies of the pituitary gland, performed before transsphenoidal surgical exploration, about 14 patients who present clinical and biological signs of Cushing disease, were reviewed retrospectively. We have always used unenhanced sagittal and coronal spin-echo T1 sequences, and coronal T1 after injection of gadolinium (1 Tesla). RESULTS: The global sensibility for detection of an adenoma was 100% (84 to 92% when the lesional localisation was considered). The injection of gadolinium increased the sensibility of 38 to 42% according the readers. 7 to 14% of the lesions were isointense after injection. The estimation of lesional size after injection was the nearer to the surgical results. The indirect sign most frequently seen (35.7 to 64.3%) was focal bulging of the sellar diaphragm. The only differences between the different radiologists, statistically significant, concerned the lesional size before injection and location of the lesion in the sagittal plane. CONCLUSION: This study confirmed the good sensibility of contrast-enhanced MRI in detection of ACTH-secreting microadenomas. The anatomo-radiological correlations are nevertheless incomplete.

Response of leucine metabolism to hyperinsulinemia in hypothyroid patients before and after thyroxine replacement.

We have investigated the effect of hypothyroidism and insulin on protein metabolism in humans. Six hypothyroid patients were studied in a postabsorptive state before and after 5 months of regular treatment for hypothyroidism (153 +/- 17 microg/day of L-T4). The effect of insulin was assessed under hyperinsulinemic euglycemic and eukalemic conditions. Insulin was infused for 140 min at 0.0063 +/- 0.0002 nmol/kg x min. An amino acid infusion was used to blunt insulin-induced hypoaminoacidemia. Whole body protein turnover was measured using L-[1-13C] leucine. When compared to L-T4-induced subclinical thyrotoxic state, hypothyroidism induced a significant decrease (P < 0.05) in leucine endogenous appearance rate (a reflection of proteolysis; 0.89 +/- 0.09 vs. 1.33 +/- 0.05 micromol/kg x min), oxidation (0.19 +/- 0.02 vs. 0.25 +/- 0.03 micromol/kg x min), and nonoxidative disposal (a reflection of protein synthesis; 0.87 +/- 0.11 vs. 1.30 +/- 0.05 micromol/ kg x min). Insulin lowered proteolysis during both the subclinical thyrotoxic and hypothyroid states. Hypothyroidism impaired the antiproteolytic effects of insulin. Thyroid hormones are, therefore, essential for the normal antiproteolytic action of insulin.

[Carbimazole and leukocytoclastic vasculitis: apropos of a case]. / Carbimazole et vascularite leucocytoclasique: à propos d'un cas.

INTRODUCTION: The authors describe the case of biopsy-proven cutaneous leukocytoclastic vasculitis secondary to treatment with carbimazole. EXEGESIS: A 78-year-old white female developed erythematous macules on the lower limbs which cleared after discontinuation of her current treatment and implementation of oral steroid therapy. Causal explorations (lack of systemic disorder or infectious disease) remain negative, except for positive immune complexes. This case clearly differs from the two cases of microvasculitis (myositis and nephritis) secondary to treatment with carbimazole previously mentioned in the literature. CONCLUSION: To our knowledge this is the first report of biopsy-proven cutaneous leukocytoclastic vasculitis associated with this antithyroid agent. Its widespread use makes awareness of the side-effect important.

[Epidemiologic characteristics of 336 thyroid cancers observed in the Auvergne region]. / Caractéristiques épidémiologiques de 336 cancers de la thyroïde observés en région Auvergne.

Patients treated and followed for thyroid cancer by a multidisciplinary group were studied between 1989 and 1993, 336 patients living in the French region Auvergne underwent total or partial thyroidectomy for thyroid carcinoma. The sex ratio was 4.3 and the median age was 52 (14-57) and 49 (17-83) in females and males respectively. Papillary carcinoma was the most common form: 76.5 of all thyroid tumors. The incidence of occult thyroid cancer was 17.4%; tumor size was smaller than for intranodular cancer (p < 0.00001). Tumor size at diagnosis of patients who died was higher than in patient who survived (p < 0.0001) and changed with histological type. It decreased between 1989 and 1993 (p < 0.01). 73% of the patients were asymptomatic before surgery, 23% described a rapid growth of their nodule. Clinically, 43.9% of the patients had a single nodule, 83% of these nodules were suspect because of their hardness. Median follow-up was 2.8 years. 279 patients are living and well, 28 were lost to follow-up and 39 died. There were 30 (8.93%) deaths due to thyroid carcinoma. In our study, significant prognostic factors for death were age at diagnosis (p < 0.0001), histological type (p < 0.0001) and nodular size (p < 0.01).

[Vitiligo in multiple autoimmune syndrome: a retrospective study of 11 cases and a review of the literature]. / Le vitiligo au cours des syndromes auto-immuns multiples: étude rétrospective de 11 observations et revue de la littérature.

PURPOSE: The occurrence in the same patient of three or more autoimmune diseases defines multiple autoimmune disease. Multiple autoimmune disease is an unusual condition in which dermatological autoimmune diseases and especially vitiligo have an important place. METHODS: We examined retrospectively 11 cases of multiple autoimmune diseases associating vitiligo. We studied the clinical characteristics of vitiligo and those of the associated autoimmune disorders. RESULTS: Type III multiple autoimmune disease was diagnosed in all the 11 cases observed. Autoimmune vitiligo was the first autoimmune disorder observed in seven cases and was bilateral, symmetrical and acrofacial in eight cases. Autoimmune thyroid disorder was associated in ten cases. Our data confirms the important association between vitiligo and thyroid autoimmune disorders. CONCLUSION: The predominant female ratio and the acrofacial topography of skin lesions could predict association with others autoimmune disorders in patients with vitiligo.

Threonine and methionine are limiting amino acids for protein synthesis in patients with AIDS.

This study was conducted to identify the most rate-limiting amino acids for whole-body protein synthesis in acquired immunodeficiency syndrome (AIDS) patients. We postulated that an essential amino acid that would be rate limiting in AIDS should have a low basal plasma concentration and should remain at a low level during amino acid infusion. Seven male AIDS patients (median age 37 y, CD4 cell count: 76 mm-3) without any clinically active opportunistic infection during the month before the experiment were infused intravenously with a complete amino acid-glucose mixture for 2.5 h. Eight healthy volunteers were used as controls. Before the infusion, the concentrations of most free essential amino acids (methionine, threonine, histidine, isoleucine, leucine and tryptophan) were significantly lower (P < 0.05) in AIDS patients than in controls. Most plasma free essential amino acids increased significantly during infusion. However, the absolute increase above basal levels for threonine, valine, lysine, (P < 0.05) and methionine (P < 0.073) was smaller in AIDS patients than in control subjects. Thus, threonine and possibly methionine may be rate limiting for whole-body protein synthesis in AIDS patients, suggesting that there are selective amino acid requirements in patients with AIDS.

Glucocorticoids do not regulate the expression of proteolytic genes in skeletal muscle from Cushing's syndrome patients.

Glucocorticoids signal enhanced proteolysis in various instances of muscle atrophy and increased gene expression of components of the lysosomal, Ca(2+)-dependent, and/or ubiquitin-proteasome proteolytic pathways in both rat skeletal muscle and myotubes. Cushing's syndrome is characterized by chronic excessive glucocorticoid production, which results in muscle wasting. We report here no change in messenger RNA levels for cathepsin D (a lysosomal proteinase), m-calpain (a Ca(2+)-activated proteinase), ubiquitin, 14-kDa ubiquitin-activating enzyme E2, and 20S proteasome subunits (i.e. critical components of the ubiquitin-proteasome proteolytic process) in skeletal muscle from such patients. Thus, in striking contrast with animal studies, glucocorticoids did not regulate the expression of muscle proteolytic genes in Cushing's syndrome. In humans, messenger RNA levels, for at least ubiquitin and proteasome subunits, are elevated in acute situations of muscle wasting, such as head trauma or sepsis. Because Cushing's syndrome is a chronic catabolic condition, we suggest that the lack of regulation of proteolytic genes in such patients may represent an adaptive regulatory mechanisms, preventing sustained increased protein breakdown and avoiding rapid muscle wasting.