Search

The care of elderly people with diabetes has become a real public health issue due to the growing number of patients. In these patients, the complications of the pathology are often combined with more particularly gerontological manifestations. It is therefore essential to adapt the therapeutic objectives according to the clinical presentation of each of them. If the new drug classes are promising because they are effective in terms of cardiovascular and renal protection, it is crucial to evaluate their benefit-risk balance for each individual. The quality of care for these elderly patients relies on a well-trained multidisciplinary medical and paramedical team., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Recognizing the role of dysglycaemia, 'ambient' hyperglycaemia, 'metabolic memory' and glycaemic variability as risk factors for macrovascular diseases is mandatory for effective diabetes management. Chronic hyperglycaemia, also referred to as 'ambient hyperglycaemia', was only fully acknowledged as a risk factor for adverse cardiovascular events when the beneficial effects of intensive glucose-lowering strategies were consolidated in the extended follow-up (> 10 years) of patients included in the United Kingdom Prospective Diabetes Study (UKPDS) and Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Study. These studies led to the concept of the glucose-lowering 'legacy effect' (metabolic memory), which depends on the duration and magnitude of glucose-lowering, and is not a 'forever' phenomenon, as demonstrated in the 15-year follow-up of the Veterans Affairs Diabetes Trial (VADT). The relatively weak evidence for linking long- and short-term glycaemic variability to vascular complications in patients with diabetes is mainly due to a reliance on observational and retrospective studies, and the lack of randomized interventional trials. However, hypoglycaemia may play an intermediary role in accentuating the link between glycaemic variability and vascular events., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Aim: The role of glycaemic control in the mortality of elderly diabetic patients remains uncertain. GERODIAB is the first multi-centre, prospective, observational study that aims to describe the link between HbA1c and 5-year mortality in French, type 2 diabetic patients aged ≥70 years., Methods: Consecutive patients (n=987; mean age 77 years) were included from 56 diabetes centres and followed for five years. Individual histories, risk factors, standard diabetes parameters and geriatric evaluations were regularly recorded. Survival was studied using the Kaplan-Meier method. Multivariable analyses used Cox regression., Results: Twenty-one percent of the patients died, 13% were lost during follow-up. Patients with a 5-year mean HbA1c in the range [40-50) mmol/mol ([5.8-6.7) %) had the highest survival (84%); those in the range [50-70) mmol/mol ([6.7-8.6) %) or <40mmol/mol (<5.8%) an intermediary survival rate (79%); patients with HbA1c ≥70mmol/mol (≥8.6%) the worst survival (71%). Patients with mean HbA1c ≥70mmol/mol (≥8.6%) had a significantly higher mortality than those with lower HbA1c (P=0.011), and HbA1c remained a significant predictor of mortality after adjusting for individual, diabetic and geriatric factors (hazards ratio [95%CI]: 1.76 [1.21 to 2.57], P=0.0033). Survival was also significantly associated with both HbA1c variability and with the frequency of HbA1c determinations., Conclusion: In this large sample of elderly French type 2 diabetic patients, an HbA1c level <70mmol/mol (<8.6%) was associated with lower mortality. The range [40-50) mmol/mol ([5.8-6.7) %) could be an acceptable target provided patients are not exposed to hypoglycaemia., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Aim: Recent guidelines for the management of type 2 diabetes (T2DM) in the elderly recommend adjusting the therapeutic target (HbA 1c ) according to the patient's health. Our study aimed to explore the association between achieving the recommended personalized HbA 1c target and the occurrence of major clinical events under real-life conditions., Methods: The T2DM S.AGES cohort was a prospective multicentre study into which 213 general practitioners recruited 983 non-institutionalized T2DM patients aged>65 years. The recommended personalized HbA 1c targets were<7%, <8% and <9% for healthy, ill and very ill patients, respectively. Major clinical events (death from any cause, major vascular events and/or hospitalization) were recorded during the 3-year follow-up. Mixed-effects logistic regression models were used for the analyses., Results: Of the 747 patients analyzed at baseline, 551 (76.8%) were at their recommended personalized HbA 1c target. During follow-up, 391 patients (52.3%) experienced a major clinical event. Of the patients who did not achieve their personalized HbA 1c target (compared with those who did), the risk (OR) of a major clinical event was 0.95 (95% CI: 0.69-1.31; P=0.76). The risk of death, major vascular event and hospitalization were 0.88 (95% CI: 0.40-1.94; P=0.75), 1.14 (95% CI: 0.7-1.83; P=0.59) and 0.84 (95% CI: 0.60-1.18; P=0.32), respectively., Conclusion: Over a 3-year follow-up period, our results showed no difference in risk of a major clinical event among patients, regardless of whether or not they achieved their personalized recommended HbA 1c target. These results need to be confirmed before implementing a more permissive strategy for treating T2DM in elderly patients., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

The burden of hypoglycaemia is important, particularly in elderly type 2 diabetes (T2D) patients. Unfortunately, however, few studies are available concerning this population. GERODIAB is a prospective, multicentre, observational study that aims to describe the 5-year morbidity and mortality of 987 T2D patients aged 70 years and older. After analyzing the frequency of and factors associated with hypoglycaemia in the 6 months prior to study inclusion, it was found that hypoglycaemia was associated with retinopathy, lower levels of LDL cholesterol and altered mini-Geriatric Depression Scale (GDS) scores., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Aim: This article is an update of the relationship between type 2 diabetes (T2D), cognitive dysfunction and dementia in older people., Methods and Results: The number of older patients consulting for diabetes who also exhibit cognitive difficulties is consistently growing because of the increased longevity of the population as a whole and, according to a number of studies, the increased risk of cognitive impairment and dementia in older diabetic patients. Many studies have demonstrated a link between poor glucose control and deteriorated cognitive function in diabetic patients. A history of severe hypoglycaemic episodes has also been associated with a greater risk of late-in-life cognitive deficits and dementia in patients with T2D. Several processes are thought to promote cognitive decline and dementia in diabetics. Based on both clinical and non-clinical findings, the factors most likely to alter brain function and structure are cerebrovascular complications of diabetes, alterations in glucose and insulin, and recurrent hypoglycaemia. Together with other diabetes complications, cognitive deficits contribute to functional impairment, increased frequency of depression-related symptoms, greater incidence of recurrent hypoglycaemia, poorer adherence to treatment and, finally, poorer prognosis, as evidenced by recent longitudinal studies., Conclusion: Clinical guidelines have recently been devised for older diabetic patients, particularly those with cognitive deficits and a reduced capacity to self-manage. In the most vulnerable patients, specific treatment strategies have been proposed for glycaemic control to limit metabolic decompensation and avoid the risk of hypoglycaemia. Educational measures, provided mainly to maintain patient autonomy and avoid hospital admission, have also been adapted according to patients' cognitive and functional status., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

In 2012, the paramedical Francophone Diabetes Society (SFD) visited Mayotte in the context of a training programme for health professionals. The training addressed diabetes prevention, self-monitoring of blood glucose and treatment management while respecting the population's cultural habits.

Aim: Cardiovascular autonomic neuropathy (CAN) is a common but often overlooked complication of diabetes. Sympathetic C-fibers innervating sweat glands can be impaired early on in patients with diabetes. In this study, SUDOSCAN, a new non-invasive device that assesses sudomotor function was compared to methods generally used for the investigation of CAN., Patients: A total of 232 patients with diabetes were measured for heart rate variability (HRV) at rest and during moderate activity. Time and frequency domain analysis techniques, including measurement of the low-frequency (LF) domain component, were assessed during HRV testing. Ewing tests, as recommended by the French Health Authority, were also done. Electrochemical sweat conductance (ESC) was measured on the hands and feet, and a risk-score was calculated., Results: Using two abnormal Ewing tests as a reference for the area under the curve (AUC) of the receiver operating characteristics (ROC) curve for SUDOSCAN, the risk-score was 0.74, with a sensitivity of 92% and specificity of 49% for a risk-score cut-off value of 35%. For the ROC curve analysis using the LF power component during moderate activity at a threshold of 90 ms(2) (first quartile) as reference, the AUC was higher for the SUDOSCAN risk-score (0.77) compared with the standard Ewing tests [E:I ratio (0.62), 30:15 ratio (0.76) and blood pressure change on standing (0.55)]. Using a cut-off value of 35%, risk-score sensitivity and specificity were 88 and 54%, respectively., Conclusion: SUDOSCAN, which allows quick quantitative assessment of sudomotor function, may be used for early screening of CAN in everyday clinical practice before resorting to the more sophisticated and specific, but ultimately more time-consuming, Ewing tests., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Aims: The GERODIAB study is the first French multicentre, prospective, observational study that aims, through a 5-year cohort follow-up, to evaluate the link between glycaemic control and morbidity/mortality of type 2 diabetic (T2D) patients aged 70 years and older. This first report describes the study population at inclusion., Patients and Methods: A total of 987 T2D autonomous patients, aged ≥70 years, were recruited between June 2009 and July 2010 at 56 investigator centres. Their general parameters, diabetes characteristics and standard geriatric parameters were recorded., Results: The patients' mean age was 77±5 years, with 65.2% aged 75 years or more. The mean BMI was close to 30 kg/m(2). Hypertension was found in 89.7% of patients, and 85.0% had at least one cholesterol abnormality. The mean duration of the diabetes was around 18 years, and the mean HbA(1c) level was about 7.5%. During the previous six months, 33.6% of patients had experienced one or several hypoglycaemias. Also, 26% of patients presented with diabetic retinopathy, 37.3% had a GFR<60 mL/min, 31.2% had coronary insufficiency, 10.1% had heart failure, 15.8% had cerebrovascular involvement and 25.6% had peripheral vascular disease of the lower extremities. In addition, 30.5% of patients had orthostatic hypotension, 12.4% had malnutrition and 28.8% had cognitive impairment, all of which were often diagnosed at inclusion. Three-quarters of patients were taking an oral antidiabetic drug and nearly six in every 10 patients were using insulin., Conclusion: This population can be considered representative of elderly, autonomous T2D patients, and its follow-up should clarify the link between glycaemic control and mortality/morbidity., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

The treatment of elderly diabetic people concerns not only doctors but also paramedical professionals. As these patients represent a heterogeneous group, treatment must be adapted to each person. The frequent occurrence of physical, sensory and cognitive disabilities must be taken into account in order to define the objectives and method of treatment. Therapeutic education must enable the patient or the carers to have a better understanding of the pathology and the therapy in order to avoid the occurrence of complications and accidents. The paramedical guide for the care of elderly diabetic people brings together all the information enabling caregivers to improve their knowledge and their practices.

Aim: The current sudomotor function tests are too time-consuming to be used for diabetic patients in daily practice. EZSCAN is a new, patented technology that measures electrochemical skin conductance (ESC) through reverse iontophoresis and chronoamperometry. The aim of the present study was to assess the sensitivity, specificity and reproducibility of the method in type 2 diabetic patients in comparison to control subjects with no risk of diabetes., Methods: A total of 133 type 2 diabetic patients and 41 control subjects were tested. Participants placed their hands and feet on nickel electrodes, and an incremental low direct current was applied to the anode for 2 min. ESC was calculated from the resulting voltage and generated current. ESC diagnostic accuracy was analyzed by ROC curve modeling, and reproducibility was assessed using Bland-Altman analysis., Results: The ESC of hands and feet was significantly reduced in diabetic patients (53±16μSi and 67±14μSi, respectively) compared with control subjects (68±16μSi and 80±7μSi, respectively; P<0.0001). ESC values had a sensitivity of 75% and specificity of 100%, with an area under the ROC curve of 0.88 at a threshold of 50% on the EZSCAN scale. Coefficients of variation in hand and foot measurements were 15 and 7%, respectively., Conclusion: The good sensitivity, specificity and reproducibility of EZSCAN make it a feasible alternative for assessing sudomotor dysfunction, a clinical manifestation of autonomic neuropathy in diabetic patients. The test takes<3 min to perform, and requires neither special patient preparation nor medical personnel training., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Aim: The aim of this paper is to provide the fundamental background of the inflammation theory associated with type 2 diabetes, to discuss the clinical consequences of low-grade inflammation, particularly in terms of cardiovascular risk, and to infer some clinical therapeutic strategies deriving from drugs that already exist or are in development., Methods: This non-exhaustive work is the result of a Pubmed(®) research, based on requests including the following keywords: diabetes, inflammation, innate immunity, obesity, reticulum endoplasmic stress, cytokines, endothelial dysfunction., Results: Obesity and type 2 diabetes are linked with a low-grade inflammation state that reflects the activation of innate immunity where metabolic, environmental and genetic factors are implicated. The role of endoplasmic reticulum stress and unfold protein response is underlined. Inflammation markers are predictive for the risk to develop diabetes, and are associated with an increased cardiovascular risk. While lifestyle modifications are followed by an improvement in inflammation markers, treatments inferred from the inflammation theory are of great interest, although quite moderate effects on glycaemic control have been observed with some of them., Conclusion: The development of molecules targeting different inflammatory mechanisms could lead in diabetic patients to improvement of both glycaemia and cardiovascular prognosis., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Diabetes and dementia, which have a complex relationship between them, are undergoing extensive growth in their fields. The occurrence of hypoglycaemia, the potential severity of which has just been pointed out in some recent studies, must be included in these relationships. In fact, diabetes is the cause of decline in cognitive functions and most certainly is involved in the occurrence of vascular dementia. The brain, which is highly dependent on glucose for its metabolism, is particularly vulnerable to hypoglycaemia in children and the elderly. Animal studies and pathoanatomical observations confirm the clinical impression of the reality of genuine post-hypoglycaemic encephalopathy. The impact of mild hypoglycaemia however is being debated. Lastly, the existence of dementia promotes the occurrence of hypoglycaemia due to disorders related to eating habits or poor treatment management. This hypoglycaemic risk however must not constitute a pretext for exaggerated laxity in achieving the blood glucose objectives., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

The prevalence of type 2 diabetes increases with age. However, the management of diabetes in the elderly has received surprisingly little attention. Diabetes in the elderly is associated with a high risk of geriatric syndromes including malnutrition and sarcopenia, functional impairments, falls and fractures, incontinence, depression and dementia. Tight glycaemic control for the prevention of vascular complications is often of limited value in the elderly. However, glycaemic control and non-pharmacological therapy may prevent diabetes symptoms and delay geriatric syndromes. The prevention, screening and treatment of both conventional diabetic complications and geriatric syndromes should be integrated in a management plan to optimize the patients' overall health status and quality of life.

Unlabelled: All diabetes specialists are aware of the frequency and severity of coronary disease in diabetics. Non-invasive diagnostic tests perform well, but they could be better., Aim: To assess the role of computed tomographic coronary angiography in diabetics. New cardiac imaging techniques such as CT coronary angiography are promising tools for the selection of patients for conventional X-ray coronary angiography, which remains the key for diagnosis and angioplasty. The limitations of CT coronary angiography, even using the most advanced machines with a 64-slice capacity, are its resolution, the need for an iodine contrast agent and the cumulative radiation from repeated examinations., Conclusion: CT coronary angiography appears to have great potential for patients at risk where non-invasive tests cannot absolutely exclude coronary disease and for the follow-up of coronary bypass surgery.

The disorder now known as metabolic syndrome has been recognized for 50 years, but its multiple definitions have led to some confusion and even doubt about its very nature. Metabolic syndrome is directly linked to the presence of android obesity, which indicates insulin resistance and lies at the root of all risk factors and early indications of type 2 diabetes. It is diagnosed by systematic measurements of waist size and its direct interpretation taking ethnic origin into account. This pragmatic approach avoids the uncertainties generated by differing definitions and is subtler than the presence or absence of metabolic syndrome in a given patient. Drug-free treatment of an android obese patient is inexpensive and effective, but this apparently simple approach masks difficulties of application. However, these are sociological problems.

Diabetes and old age come together to increase the frequency and severity of coronary heart disease. Often clinically nearly silent, symptoms frequently manifest dramatically, to such an extent that the question of screening should be raised, as in younger subjects. Preventing these manifestations relies on better management of the cardiovascular risk factors and obtaining good blood glucose control, but here progress remains necessary, which also requires adapting to the older patient's clinical and psychological condition. Cardiovascular autonomic neuropathy is a frequent degenerative complication in diabetics, particularly in the oldest subjects. The most severe types have serious clinical consequences, thus a higher mortality factor, but the mechanisms remain poorly understood. As for coronary heart disease, the therapeutic tools have expanded these last few years and should be thought out in relation to the geriatric evaluation, with the objective of improving these patients' quality of life. Therefore, a necessary distinction should be made between subjects who have aged successfully, whose management, ultimately, differs little from younger subjects, and frail elderly individuals for whom exploratory techniques and treatment should be adapted.

All available estimations agree that the French population is aging and that the proportion of diabetics in the elderly population is increasing. The prevalence of diabetes could be about 10% in the over 65 y population. The fact that diabetes has an effect on brain function is widely accepted, but there are very few studies providing pertinent details. Diabetes is known to affect brain function, potential consequences including cognitive decline, dementia, depression, and stroke. These complications are frequently associated, leading to poor quality-of-life with considerable social and economic impact. While the results of different studies can be contradictory, there is an overall trend towards the conclusion that diabetes, often associated with high blood pressure, contributes to cognitive decline in elderly diabetics as well as to an increased frequency and severity of cerebral vascular events. These considerations point out the importance of proper management of diabetes in the elderly population and the need for cooperative studies to determine the role of diabetes and different cardiovascular risk factors in the development of dementia, stroke, and depressive syndromes whose consequences are probably underestimated.

Context: The Metabolic syndrome is considered to be an important public health problem, but few epidemiological studies have defined the present situation in France. EPIMIL is a prospective epidemiological study that began on February 1, 2003., Subjects and Methods: This study was designed to identify the clinical and laboratory parameters of metabolic syndrome and cardiovascular risk factors in a population of 2045 male military personnel based in the Paris region. The initial 1-year cross-sectional study will be followed by a 10-year follow-up and patient care., Results: The 2045 subjects included 185 (9%) presented at least 3 of the 5 NCEP ATP III criteria defining metabolic syndrome. They were significantly older (42.2 +/- 8.5 yrs) than the other subjects (37.3 +/- 8.7 yrs, P<0.001), had a higher BMI (29.5 +/- 3.4 vs 24.8 +/- 2.9 kg/m2, P<0.001) and a greater body weight at age 20 (75.4 +/- 11 vs 70.4 +/- 8.5 kg, P<0.01). Smoking, little physical activity and family histories of diabetes and arterial hypertension were more frequent in these men. While levels of the cholesterol and CRP us were higher, Lp(a) and homocysteine concentrations were normal. Plasma insulin and BMI (r = 0.456 P<0.0001) and plasma insulin and waist circumference (r = 0.446 P<0.0001) were well correlated. Lastly, plasma insulin, free fatty acids and cardiovascular risk increased steadily with the increase in the number of metabolic syndrome criteria., Conclusions: These results in a large and particularly uniform population of men show the prevalence of metabolic syndrome in adult men, and demonstrate its link with insulin resistance. Men with several risk factors require specific care, particularly for hypertension and dyslipidemia; the effectiveness of this care will be evaluated during the follow-up period.

Ketone body determination is indicated in all diabetic patients when the risk of ketotic decompensation exists. New methods of screening for ketosis, in particular capillary blood ketone body determination, provide analytical, technical and clinical advantages compared to the conventional ketonuria. It is proposed that a diabetic patient with hyperglycaemia (capillary blood glucose > 2.50 g.l(-1)) and capillary blood ketone bodies exceeding 0.5 mmol.l(-1) requires therapeutic management. For values greater than 3 mmol.l(-1) or in case of more serious clinical symptoms, hospitalisation is indicated, considering the high probability of ketoacidotic decompensation. The advantages of capillary blood ketone body determination including easy use, and rapid and objective results may improve management of the diabetic patient, especially in emergency situations. However, prescription by a physician of capillary blood ketone body determination should be offered to targeted populations that have a high risk of ketoacidotic decompensation, after providing education to patients that is above all aimed at preventing this metabolic complication. In this context of determining ketone bodies in capillary blood, the term "capillary blood ketone bodies" is therefore preferable to the term "capillary blood beta-hydroxybutyrate determination". Indeed, it appears more appropriate, simple, descriptive and significant both for health-care staff and for patients.

Objective: In patients with maternally inherited diabetes and deafness (MIDD), due to 3 243 A > G mutation of mitochondrial DNA (mtDNA), diabetes may present with variable phenotypes., Objective: To ascertain the existence of two distinct phenotypes, MIDD1 and MIDD2, in a series of patients with MIDD., Design: Multicenter prospective study., Patients: 77 patients with diabetes and the mtDNA 3243 mutation and 139 control patients with type 1 (T1D) or type 2 (T2D) diabetes, matched according to initial presentation of diabetes, age at onset, sex, and duration of diabetes (24 T1D and 115 T2D, including 55 treated with insulin)., Measurements: Anthropometric characteristics (height, body weight, body mass index [BMI], sex), family history of diabetes, and characteristics of diabetes (age at onset, treatment, hemoglobin A1c [HbA1c]), extrapancreatic manifestations., Results: In 13 cases (17%, MIDD1), diabetes presented as insulin-dependent from the onset, with ketoacidosis in 6 cases. In 64 cases (83%, MIDD2), diabetes resembled T2D, and was treated with diet in 12 cases, oral hypoglycemic agents in 21 cases, or insulin in 31 cases. Compared with patients with MIDD2, patients with MIDD1 were characterized by lower age at onset of first manifestation of MIDD (25.4 +/- 9.6 vs 33.7 +/- 13.2 Years, P<0.0005), lower body weight (49.1 +/- 7.4 vs 56.3 +/- 10.9 kg, P<0.0025), lower BMI (18.2 +/- 2.3 vs 20.9 +/- 3.6 kg/m2, P<0.0005), and higher HbA1c levels (9.5 +/- 2.0 vs 7.5 +/- 1.6%, P<0.0005). Frequency of family history of diabetes and of extrapancreatic manifestations was the same in both MIDD subtypes. No difference was found within the MIDD2 subtype when comparing patients treated with or without insulin. Compared with matched controls, patients with MIDD had a lower BMI (MIDD1/T1D 18.2 +/- 2.3 vs 24.0 +/- 3.6 kg/m2 and MIDD2/T2D 20.9 +/- 3.6 vs 30.2 +/- 5.9 kg/m2, P<0.0025). Lastly, male patients with MIDD had a shorter height than controls (MIDD1/T1D: 166.1 +/- 3.2 vs 177.3 +/- 6.6 cm and MIDD2/T2D: 168.4 +/- 7.2 vs 173.6 +/- 6.6 cm P<0.025)., Conclusions: These results confirm the existence of two different phenotypes in MIDD, MIDD1 and MIDD2, which may be related to the severity of the mitochondrial disease. The role of other genetic and/or environmental factors in the variable phenotype of MIDD remains to be elucidated.

The relationship between diabetes mellitus and cancer of the pancreas is complex and incompletely understood. Nevertheless, it is generally agreed that new-onset diabetes in a patient over 50 Years old is a classical indication of pancreatic cancer. But there is no official directive in France that a scan should routinely be performed in such cases. We have studied 115 patients aged over 50 who were hospitalized for new-onset diabetes (fewer than 30 days) whose instability required insulin treatment. Routine imaging revealed abdominal disorders in 14 patients, 6 (5.2%) of whom were suffering from pancreatic adenocarcinomas. No clinical indication or laboratory test, apart from an unusually severe anorexia, suggested the discovered disorders. We therefore routinely carry out a pancreas scan, preferably by MRI, on all patients over 50 Years old presenting with new-onset diabetes, even if there are not clinical or laboratory indications of cancer. This is the only way in which small pancreatic cancers can be detected, thus providing the best hopes for successful treatment. Unfortunately, too often, this approach also detects only tumors that are already well developed. However, nowadays, it is not conceivable for a clinical team to discharge a patient from hospital with such a serious disease undiagnosed.

Amoebiasis is the second most common parasitic disease worldwIde. It occurs mainly in developing countries. A high percentage of people in countries where it is endemic are asymptomatic carriers. It results in severe disease that can be fatal in rare cases. Diabetics are at increased risk of exposure as travel to countries where it is endemic becomes more frequent, as indicated by the present case. This patient suffered from amoebiasis that produced an amoeboma which is most rare in cases of colonic amoebiasis. The clinical picture was that of an occluding gut tumor, but it was treated only with drugs. Retrospective studies show that diabetics are at increased risk of suffering severe complications after amoebic infection. The frequency and severity of this diabetes-amoeba association requires patients to take prophylactic measures, especially when travelling in developing countries.

Normalization of blood pressure is today as necessary as an optimal blood glucose control. These targets aim at reducing the negative consequences of hypertension which is particularly frequent and of poor prognosis for these patients. Nevertheless, the definition of the real blood pressure of these patients is uneasy because of the lack of precision of clinical blood pressure measurement. New methods have been developed to address this insufficiency. Home blood pressure monitoring is characterised by good compliance and accuracy, but patient education needs a special training and validated automated devices. This method has to be proposed to the diabetic population as soon as hypertension may be a problem. These patients will contribute to monitor their own blood pressure as they do it with blood glucose control.

The poor prognosis of coronary artery disease along with the inaccuracy of available testing methods have favoured the development of new screening techniques. One such innovation involves measuring the coronary artery calcium score (CAC). Through computed tomography, this test quantifies the amount of calcium deposited in coronary arteries, itself a reflection of the degree of atherosclerosis. This investigation is a prospective study of 48 diabetic subjects comparing the performance of CAC score with the gold standard testing methods. The results of our study showed that, due to its high negative predictive value, 5 invasive tests were performed needlessly as these subjects had very low CAC scores. At this time, the CAC score is not recommended for every patient but rather on a case-by-case basis. However, it may soon emerge as the next step after the ECG in the evaluation of coronary artery disease. This would alleviate the need for more invasive tests in those patients for whom such investigations are deemed unnecessary. The CAC score, when matched for age, sex and other variables, could also serve as an indication for prescribing medications such as statins, along with other therapeutic interventions. Diabetologists, cardiologists and radiologists must work together in order to gain a better understanding of these new techniques. This may facilitate the emergence of a new approach to the treatment of coronary artery disease.

Background: Clinical presentation and natural history of diabetes are somewhat different in Black Africans compared to Caucasians. This peculiar disease course could be at least partly related to a specific genetic profile that has not been studied in this population., Methods: Medical backgrounds, anthropometric and biologic parameters were obtained from 69 diabetic subjects in Dakar, Senegal, in 1998. Blood anti GAD and Islet Cell Antibodies were studied, using RIA and immunofluorescence assay. The HNF-1alpha gene was sequenced searching the Gly574Ser mutation, previously described in MODY 3., Results: Among these 69 diabetic patients, 11 (16%) were found to have the G574S mutation affecting the HNF-1alpha. These 11 patients carrying the mutation were compared respectively with the 58 non carriers. Mean age (57.5 yr. +/- 11 vs 51.1 yr. +/- 15) and duration of diabetes (11.9 vs 6.7 yr), were similar in the two groups. BMI was not different in patients with the mutation (26.3 vs 23.3, p=0.06). Metabolic control (Glycosylated hemoglobin) was poor in the two groups (9.5% vs 9.2%). Chronic complications were equally found in the patients, but no mutation carrier had macroangiopathy. None of the anti GAD positive or ICA positive patients had the mutation., Conclusions: The HNF-1alpha Gly574Ser mutation was found in 16% of cases in a 69 diabetic patients group in Senegal. Diabetes was as severe as in non carriers of mutation. This mutation has been implicated in atypical diabetes of Afro-American children. The study confirms its prevalence in Africans with diabetes.

Epidemiologic studies underline the responsibility of the cumulative effect of cardiovascular risk factors on mortality and morbidity. These data have let to the elaboration of equations predicting the risk of coronary heart disease. This probability, which defines the absolute cardiovascular risk, can be assessed using Framingham formula, Laurier-Chau's risk table, derived from the Framingham model, Ducimetière and PROCAM study' prediction models. The main interest of these equations is to give the cumulative effect of risk factors. They can be used to evaluate the advantages of primary prevention. Equations do not take into account several factors, such as body mass index, fibrinogene and lipoprotein (a) values, which have an influence on cardiovascular mortality while others are studied in their qualitative aspects (smoking status, diabetes). Furthermore, equations are not applicable to the whole population. The absolute cardiovascular is a useful tool from an epidemiologic and individual standpoint, but the limits of the different models must be known.

Glucotoxicity generated by hyperglycemia creates a vicious circle worsening the imbalance of diabetes mellitus. A pump-optimized transient insulin treatment can be used to break this fate and restore some degree of insulin sensitivity in uncontrolled type 2 diabetes. The aim of this retrospective study was to evaluate type 2 diabetics with a secondary failure to a maximal oral antidiabetic therapy, treated with a transient subcutaneous insulin therapy during 3 days. The following criteria were analysed: delay before permanent insulin treatment, prognosis factors of evolution, weight evolution and glucose control in patients maintained under oral treatment. We studied 250 type 2 diabetics, and 515 insulin infusions. The average follow-up was 3.5 years. At the end of the follow-up 63 patients required insulin from the inception of the study (Group 1), 76 secondarily resumed insulin (Group 2), and 111 remained with oral treatment (Group 3). Patients in Group 1 were significantly older, with higher HbA1c and a lower body mass index (BMI). On average, the patients in Group 3 were submitted to less than 2 insulin infusions, their BMI from the beginning to the end of the follow-up remained stable, while HbA1c improved. We conclude that transient optimized insulin treatment during 3 consecutive days is effective. Thus, 45% of the initial global population remain under oral therapy after 3.5 years with a better glucose control and a stable weight.

Pituitary abscess is not rare. Clinical and radiological features in a primitive pituitary abscess are reported. Transphenoidal surgery revealed an abscess. Preoperative diagnosis of pituitary abscess remains difficult. Sellar round cystic mass isointense to grey matter on T1, high intensity signal on T2, with a peripheral rim enhancement following gadolinium injection associated with thickened stalk and diabetes insipidus may be suggestive of pituitary abscess.

This study assessed gastric neuropathy in type 1 diabetes mellitus and its relationships with cardiac autonomic neuropathy. Fifty-four asymptomatic type 1 patients (43 +/- 12 years) and 15 healthy subjects participated in the study. Cutaneous electrogastrography (EGG) was recorded for 4 h before, during, and 4 h after the ingestion of a standard meal. EGG frequency was divided into three bands: bradygastria [< 2 cpm), normal (2-4 cpm) and tachygastria (4-10 cpm)]. Assessment of diabetic autonomic neuropathy was based on Ewing tests and time and frequency domain indexes, which were analyzed from 24-h continuous ECG recordings. Tachygastria was significantly more common in diabetic patients than in controls throughout the recording period (38 +/- 5 vs 23 +/- 11.8%, p < 0.001), before (37 +/- 6 vs 26.5 +/- 8.9%, p < 0.001), during (41 +/- 7.8 vs 23 +/- 10.5%, p < 0.001) and after the meal (37 +/- 6.9 vs 29 +/- 9.8%, p < 0.001). The percentage of dominant frequency in the normal range was significantly lower in diabetic patients than controls (49 +/- 6 vs 63.3 +/- 11.1%, p < 0.001). Tachygastria was correlated with duration of diabetes (r = 0.234, p < 0.05), but not with glycaemic control. Abnormalities in gastric myoelectrical activity were not correlated with Ewing tests or time and frequency domain indexes.

To determine the effect of benfluorex on glycaemic control in obese insulin-requiring Type 2 diabetes, 76 patients (aged 53.8 +/- 12.8 years) receiving insulin (> or = 0.5 IU/kg) and an appropriate low-calorie diet were evaluated after a 1-month run-in followed by a 3-month double-blind treatment period (3 tablets daily) with benfluorex (B; n = 37) vs placebo (P; n = 39). At inclusion, the B and P groups respectively did not differ in body weight (80.9 +/- 10.3 vs 77.2 +/- 9.1 kg), body mass index (BMI) (30.1 +/- 4.6 vs 29.0 +/- 2.3 kg/m2) or fasting blood glucose (11.22 +/- 4.33 vs 10.35 +/- 4.42 mmol/l). However, daily insulin dose and HbA1c levels were higher in the B group (59.9 +/- 18.6 vs 50.4 +/- 12.8 IU, p = 0.012; and 7.72 +/- 1.60 vs 6.96 +/- 1.27%, p = 0.025, respectively). After 3 months of treatment, the decrease in daily insulin dose was greater in the B group (8.7 +/- 10.1 vs 2.7 +/- 8.1 IU; p = 0.032), with a decrease in HbA1c (-0.73 +/- 1.74%, p = 0.026), vs no change in the P group (+0.01 +/- 1.65%, NS) and a tendency towards a greater decrease in fasting blood glucose (-1.43 +/- 5.41 vs +0.42 +/- 3.78 mmol/l respectively). Body weight and BMI were also lower in the B group (1.77 ñ 2.27 vs 0.21 ñ 2.68 kg, p = 0.013; and 0.64 +/- 0.84 vs 0.07 +/- 1.07 kg/m2, p = 0.019, respectively) in parallel with the decrease in insulin dose. Triglycerides decreased in the B group vs an increase in the P group (-0.54 +/- 2.04 vs +0.21 +/- 0.70 mmol/l p = 0.06). Total cholesterol decreased within the B group (-0.47 +/- 1.01 mmol/l; p = 0.013) and vs the P group (intergroup p = 0.006). Adverse events were reported in 11 patients in the B group vs 5 in the P group (NS), causing dropout in only one case (intercurrent illness, P group). Addition of benfluorex in obese insulin-requiring Type 2 diabetes thus enhances glycaemic control and lowers both daily insulin requirement and body weight. Benfluorex + insulin is a valid alternative for obese patients who remain poorly controlled despite insulin or who require high doses of insulin.

Diabetes is a worldwide public health problem made more acute in Africa by low socio-economic standards. Cases with an unusual clinical course are frequent and probably related to tropical diabetes, a syndrome that has not yet been precisely defined. This study reports the results of a prospective study carried out in Cameroon on 550 diabetic patients attending the Yaounde Central Hospital who were followed between December 1990 and July 1994. They were classified according to WHO criteria into 136 insulin-dependent diabetes mellitus (IDDM) (24.7%), 405 non-insulin- dependent diabetes mellitus (NIDDM) (73.7%) and 9 diabetes secondary to other diseases (1.6%). No cases of malnutrition-related diabetes mellitus (MRDM) were found, but 18 subjects were considered to have so-called "African diabetes". Investigation of the cohort showed epidemiological and clinical features markedly different from those of Caucasian diabetic subjects. The age of onset in IDDM occurred in all age groups, with a mean (+/- SD) close to that of NIDDM (40.9 +/- 4.8 years vs 49 +/- 10.9; P < 0.001). A clear male preponderance was found (M/F sex ratio = 1.63), as it has been reported in most studies from sub-Saharan Africa, in contrast with the slight female predominance noted in the Sahel and Saharan countries. An increased prevalence of young and non-obese NIDDM was also found. Seventy-nine NIDDM cases (19.5%) were detected in individuals under 40 years of age, including 31 with normal weight. Many atypical features were noted: IDDM in obese patients, NIDDM in ketotic subjects and patients with varying insulin requirements, all of which led to difficulties in classifying many diabetic patients according to current practices. All these uncommon features are concordant with the nature of tropical diabetes, including not only MRDM but also African diabetes which occurs in individuals older than MRDM patients who show no signs of malnutrition. Thus, tropical diabetes is apparently a syndrome with aetiological heterogeneity which requires further definition through clinical, genetic and immunological studies.

Prolactin radioimmunoassay was carried out before and 15, then 30 min after intravenous infusion of protireline (0.2 mg) in 3 groups of male patients: 7 with reactive arthritis (HLA B27: 6; age: 25 +/- 6.3 yr), 13 with ankylosing spondylitis (HLA B27: 11; age: 33.2 +/- 14.7 yr), 5 with psoriatic arthritis (HLA B27: 1; age: 28.8 +/- 6.3 yr). The same test was carried out in sex-age-body mass index matched controls. Only the patients with reactive arthritis presented dynamic hyperprolactinaemia 15 and 30 min after protireline infusion and none of ankylosing or psoriatic arthritis groups. A complete failure of bromocriptine was observed in reactive arthritis. In 2 cases of psoriatic arthritis, adding bromocriptine to gold salts and nonsteroidal anti-inflammatory drug was followed by a drastic efficacy with spectacular improvement in clinical, biological and occupational status. Because none of the cases had hyperprolactinaemia, bromocriptine acted probably had an intrinic anti-inflammatory effect independent of its antiprolactinic effect.

The aim of the present study was to assess the possible modifications in the parameters of red cell aggregation and blood and plasma viscosity in 92 diabetic patients compared to 82 non diabetic control subjects. Based on the presence of microalbuminuria (> 30 mg/24 h) and/or retinopathy each group of diabetic patients was divided into two subgroups. This study shows increased red cell aggregation and blood viscosity among diabetic patients with microangiopathy. There was a very good correlation between fibrinogen level and the different rheological measurements. The results of this study confirm the importance of the blood rheology abnormalities observable in diabetes. These disorders increase peripheral vascular resistances and ischemia and therefore worsen diabetic nephropathy and retinopathy.

The aim of the present study is the evaluation two years apart of the effect of initial blood pressure values on ambulatory blood pressure determinations on the rise of microalbuminuria in 77 Type 1 diabetic patients. At the beginning of the study, subjects with incipient nephropathy have a whole day systolic and diastolic blood pressure greater than those whose microalbuminuria is below than 30 mg/24 h (127.7 +/- 15.1 mmHg versus 115 +/- 14.3 mmHg, p < 0.001; 76.6 +/- 8.1 mmHg versus 72.5 +/- 7.3 mmHg, p < 0.05). Among patients whose initial microalbuminuria was lower than 30 mg/24 h, incipient nephropathy will not be dependent on initial blood pressure values but conditioned by patients' age and duration diabetes of mellitus. On the other hand, blood pressure increases the microalbuminuria of the patients who had incipient nephropathy at the beginning of the study. In patients with diabetes mellitus, ambulatory blood pressure monitoring appreciates the impact of the pressure rise on the kidney, retina and heart.

Cardiac autonomic neuropathy frequently affects Type 1 and Type 2 diabetic patients. This disease is distinguished by visible clinical consequences which can be tragic. It can also worsen a number of degenerative complications. Therefore, cardiac autonomic neuropathy seems to play a deciding role in silent ischaemia and in dysregulations of blood pressure. Clinical explorations continue to be based on the tests validated by Ewing, but the development of simple and reliable techniques seems to be an objective the interest of which cannot escape any clinician.

Kaposi's sarcoma was diagnosed in a 62 year old female at the last stage of an indefined malignant lymphoma. Clinically and histopathologically, some cutaneous aspects were consistent with mycosis fungoides. However, the histological examination of lymph-nodes led to the diagnosis of Hodgkin's disease, sometimes associated with features of Kaposi's sarcoma. During the past few years, the occurrence of Kaposi's sarcoma in the course of cancers, malignant lymphomas and especially during Hodgkin's disease, has been reported. It has been suggested that immunosuppressive therapy undertaken for the initial tumor could account for a viral carcinogenesis. In this respect, the vascular proliferation observed in Kaposi's sarcoma could be compared with the lymphocyte induced angiogenesis, which occurs during the experimental graft versus host reaction. Therefore, Kaposi's sarcoma could be the result of a tumoral rejection. In the case of our observation, it does not seem possible to diagnose an angio-immunoblastic lymphadenopathy; but it is of interest to note that, in this later disease, histological features of vascular neogenesis have also been reported.