Search

With the increase in international travel and development of insecticide resistance, a re-emergence of the bed bug has been observed since the 2000s and it is becoming a worldwide public health problem. Hospitals and other medical settings have not been spared, while the cases reported remain limited. However, there are no specific recommendations for the healthcare settings in the literature.To report our experience of a bed bug infestation in a medical unit, in the French University Hospital Centre of Brest, caused by the admission of a patient carrier in October 2020. We described the practical methods used to control bed bugs infestation, evaluated the cost of this episode and created a specific procedure to take care of at-risk patients or known carriers of bed bugs.The decision to close the unit for global treatment was taken after the investigations using a sniffer dog revealed that four rooms were infested. The closure lasted 24 days. We estimated the total cost of the infestation to be approximately US$400,000. No other wave of infestation occurred. We created a specific protocol of care for patients who were known carriers or at risk of carriage of bed bugs to graduate a strategy of control.Bed bug infestations in health facilities have a major impact on the care of patients and relevant economic consequences. Prevention and education policies are an essential starting point to respond to the scale of the phenomenon.

Throughout the world, millions of people suffer from fragilizing osteopathies such as osteomalacia and osteoporosis. Osteomalacia is a rare disorder, corresponding to mineralization abnormalities in adult bone, as opposed to rickets in children. Renal phosphate loss and hypophosphatasia are the main causes of vitamin-resistant osteomalacia. Diagnosis is based on clinical history, phosphocalcic metabolism assessment and, if necessary, molecular characterization, and must be rapid in order to initiate the most appropriate treatment and consider new treatments such as burosumab if necessary. Osteoporosis is characterized by reduced bone mass and strength, which increases the risk of fragility fracture. Fracture-related burden is expected to increase over the coming decades linked to the aging of population and a treatment gap. In order to reduce this treatment gap, it is important to develop two strategies: improvement of screening and of treatment. Systematic screening using the FRAX® fracture risk assessment tool could be useful to increase anti-osteoporosis medical treatment and reduce fracture rates. The question of treatment sequencing in osteoporosis is another challenge, notably after denosumab cessation, complicated by a decrease in bone mineral density and increased risk of fracture. New treatments are also available, including romosozumab, a humanized monoclonal antibody, which promotes bone formation and inhibits bone resorption by inhibiting sclerostin. Romosozumab is approved in several countries, including France, for treating severe osteoporosis in postmenopausal women at high risk of fracture and free of cardiovascular comorbidity. Endocrinologists need to be aware of these fragilizing osteopathies in order to improve both diagnosis and treatment.

ObjectiveTurner Syndrome is associated with several phenotypic conditions associated with a higher risk of subsequent comorbidity. We aimed to evaluate the prevalence of congenital malformations and the occurrence of age-related comorbid conditions and to determine whether the frequencies of congenital and acquired conditions depend on X chromosome gene dosage, as a function of karyotype subgroup.Design and methodsThis national retrospective observational cohort study includes 1501 patients. We evaluated the prevalence of congenital malformations and the cumulative incidence of subsequent specific comorbidities at five-year intervals, from the ages of 10 to 30 years, with stratification by karyotype subgroup: 45,X (n = 549), 45,X/46,isoXq (n = 280), 46,X,r(X)/46,XX (n = 106), 45,X/46,XX (n = 221), presence of Y (n = 87).ResultsMedian age was 9.4 (3.7–13.7) years at first evaluation and 16.8 (11.2–21.4) years at last evaluation. Congenital heart (18.9%) malformations were more frequent in 45,X patients, and congenital renal (17.2%) malformations were more frequent in 45,X, 45,X/46,isoXq and 46,X,r(X)/46,XX patients than in those with 45,X/46,XX mosaicism or a Y chromosome (P ConclusionThese data suggest that X gene chromosome dosage, particularly for Xp genes, contributes to the risk of developing comorbidities.

The 2017 Endocrine Society annual meeting included several communications and debates on the conservative adrenal surgery in bilateral hereditary pheochromocytomas (BHP), bilateral adrenal macronodular hyperplasia (BAMH) and primary hyperaldosteronism (PHA). The general principle is to preserve a part of the adrenal cortex to prevent the occurrence of a definitive adrenal insufficiency. In BHP, cortical sparing surgery allows more than 50% of patients to maintain normal corticotropic function at 10 years with a low recurrence rate (~ 10%). Since the adrenal medulla cannot be removed entirely, recurrence seems inevitable and long-term follow-up is essential. Individual risk of malignancy must be taken into account. In BAMH responsible for Cushing syndrome, unilateral adrenalectomy induces a normalization of urinary free cortisol in 92 to 100% of cases and even corticotropic insufficiency in 40 to 100% of cases. This is most often transient. Late recurrences of Cushing's syndrome may occur in 13 to 60% of cases. Prolonged patient monitoring is therefore essential. In PAH with lateralized aldosterone production, minimally invasive partial adrenal surgery, which consists of removing only the adrenal adenoma visualized at TDM, allows an improvement blood pressure in about 94% of patients. However, failure or recurrence may occur. Its place therefore remains marginal in the treatment of the lateralized PAHs.

Resume L’augmentation de la prevalence du diabete gestationnel et l’interet de son traitement incitent les professionnels de sante a optimiser sa prise en charge. Notre service hospitalier a mis en place un projet de telemedecine appele « SUIDIA » (pour SUIvi du DIAbete), developpe avec l’aide de l’Agence regionale de sante (ARS) pour repondre a cette demande. Notre evaluation a montre que le suivi par telemedecine n’a pas d’impact sur les complications materno-fœtales. La majorite des patientes et des professionnels de sante se sont declares satisfaits du suivi et de la prise en charge.

Introduction Le dosage de l’oestradiol est utilise pour s’assurer de la bonne freination de l’axe gonadotrope chez des patientes non menopausees atteinte de cancer du sein. Nous rapportons une interference entre le Fulvestrant (FASLODEX®), antagoniste competitif des recepteurs aux œstrogenes (RE) et le dosage d’estradiol. Observation Il s’agit d’une femme de 27 ans atteinte d’un cancer du sein droit infiltrant SBR II, RH+, HER2 non surexprime, diagnostique en 2016, metastatique sur le plan osseux, traite par chimiotherapie neo-adjuvante, chirurgie, radiotherapie et une hormonotherapie par agoniste de la GnRH et un anti-aromatase. Evolution en juillet 2019 avec de nouvelles metastases osseuses et reprise de la radio-chimiotherapie, et modification en octobre 2019 de l’hormonotherapie avec introduction du Fulvestrant associe a l’agoniste de la GNRH. Un controle du bilan hormonal a un mois retrouve une LH a 0,05mUI/L, une FSH a 5,87mUI/L mais avec une œstradiolemie a 205 pg/ml, et recontrolee augmentee a plusieurs reprises. Une ovariectomie bilaterale est realisee en fevrier 2020 avec une œstradiolemie post-operatoire a 270 pg/mL puis 339 pg/mL (dosage Abott Architect) en avril 2020 alors que la TEP-TDM ne retrouve pas de maladie persistante. Une interaction de dosage est alors suspectee. Discussion Le Fulvestrant a une affinite comparable a l’œstradiol sur les RE et une structure similaire a l’œstrogene, et entraine des interferences par reactions croisees avec les immuno-dosages de nombreux kits (Roche ELECSYS, VITROS, Siemens Centaur, et Abott Architect). Sous Fluvestrant, un dosage par LC/MS est preferable.

Pregnancy is an immunological paradox that implies that a semi-allogeneic fetus is not rejected by the maternal immune system, from implantation of the embryo to delivery. Progesterone (P4), estradiol (E2) and human chorionic gonadotropin (hCG), contribute to the transformation of immune cells in a transient tolerance state, necessary to the maintenance of pregnancy. The effects of pregnancy hormones depend probably of their maternal plasma level. hCG is dangerous at high concentrations because it can stimulate autoantibodies production, whereas in physiological concentrations, hCG, P4 and E2 upregulate immune response expanding regulatory T and B cells, allowing the fetus to grow within the maternal uterus in a protective environment. A second example of fetal-maternal relation found recently is the role of maternal nutrition on development of the fetal hypothalamic neurons. Experiments in mice fed on a high fat diet reveal a critical timing when altered maternal metabolism affect formation of hypothalamic neurocircuits of the offspring and predispose him to long-term metabolic disorders.

Background Recently discovered mutations of NR3C1 gene, encoding for the GR, in patients with glucocorticoid resistance and bilateral adrenal incidentalomas prompted us to investigate whether GR mutations might be associated with adrenal hyperplasia. Objective The multicenter French Clinical Research Program (Muta-GR) was set up to determine the prevalence of GR mutations and polymorphisms in patients harboring bilateral adrenal incidentalomas associated with hypertension and/or biological hypercortisolism without clinical Cushing’s signs. Results One hundred patients were included in whom NR3C1 sequencing revealed five original heterozygous GR mutations that impaired GR signaling in vitro. Mutated patients presented with mild glucocorticoid resistance defined as elevated urinary free cortisol (1.7 ± 0.7 vs 0.9 ± 0.8 upper limit of normal range, P = 0.006), incomplete 1 mg dexamethasone suppression test without suppressed 8-AM adrenocorticotrophin levels (30.9 ± 31.2 vs 16.2 ± 17.5 pg/mL) compared to the non-mutated patients. Potassium and aldosterone levels were lower in mutated patients (3.6 ± 0.2 vs 4.1 ± 0.5 mmol/L, P = 0.01, and 17.3 ± 9.9 vs 98.6 ± 115.4 pg/mL, P = 0.0011, respectively) without elevated renin levels, consistent with pseudohypermineralocorticism. Ex vivo characterization of mutated patients’ fibroblasts demonstrated GR haploinsufficiency as revealed by below-normal glucocorticoid induction of FKBP5 gene expression. There was no association between GR polymorphisms and adrenal hyperplasia in this cohort, except an over-representation of BclI polymorphism. Conclusion The 5% prevalence of heterozygous NR3C1 mutations discovered in our series is higher than initially thought and encourages GR mutation screening in patients with adrenal incidentalomas to unambiguously differentiate from Cushing’s states and to optimize personalized follow-up.

Today, primary hyperparathyroidism (PHPT) is frequently diagnosed at an asymptomatic stage. New international guidelines presented at the Endocrine Society congress update the management of this disease. Normocalcemic PHPT is part of the diagnostic spectrum of PHPT, its natural history is poorly known, and monitoring is proposed once secondary HPT has been eliminated. Bone involvement, classically predominant in cortical bone, also affects trabecular bone. Osteodensitometry is poorly effective at the vertebral level and new methods (trabecular bone score [TBS], vertebral fracture assessment [VFA]) should improve the assessment of the risk of fracture. The kidney is the most frequently symptomatic organ, and an imaging workup as well as urinary tests are recommended in all patients when searching for causes of lithiasis or nephrocalcinosis. More than 10% of PHPT cases are related to a germinal mutation: these patients should be identified to optimize their management and that of their relatives. Medical treatment is reserved for patients for whom surgery is not indicated or possible: cinacalcet is effective for calcemia, the bisphosphonates are effective for bone involvement. Vitamin D deficiency can be corrected as long as calcemia and creatinuria are monitored. Surgical treatment is recommended in case of pronounced hypercalcemia, bone or renal involvement, and age less than 50 years and in patients in whom monitoring is refused or impossible. Studies have shown that asymptomatic PHPT evolves little in monitored patients.

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.

Resume Le syndrome de Cushing est une affection rare dans la population generale dont la frequence est estimee a 1 nouveau cas par an et par million d’individus ; il est encore moins frequent d’en faire le diagnostic au cours de la grossesse. Nous rapportons le cas d’une patiente prise en charge a 27 SA pour un tableau d’hypertension arterielle associee a des troubles hydroelectrolytiques. Le syndrome de Cushing a ete confirme par le dosage du cortisol salivaire et de l’adrenocorticotropic hormone (ACTH). L’IRM a mis en evidence une tumeur surrenalienne unilaterale de 90 mm. La severite de l’hypertension et des troubles hydroelectrolytiques, d’une part, et l’absence de certitude diagnostique quant a la nature de la tumeur, d’autre part, ont impose une surrenalectomie a 29 SA. Douze jours apres l’intervention, la degradation brutale des echanges fœto-placentaires a necessite la realisation d’une cesarienne et a permis la naissance d’un enfant vivant.

Resume La prevalence de l’osteoporose, maladie systemique caracterisee par une densite minerale osseuse abaissee, ne cesse de s’accroitre avec le vieillissement de la population d’ou un risque accru de fractures aux consequences medicales et socio-economiques nefastes. Une meilleure connaissance des voies de regulation du remodelage osseux a permis l’avenement de nouvelles cibles therapeutiques. Ainsi, l’anticorps monoclonal denosumab, anti-recepteur activateur du NF-κB ligand (facteur indispensable a l’osteoclastogenese) inhibe de facon rapide et reversible la resorption osseuse. Une seule injection sous-cutanee semestrielle est requise, avantage notable par rapport aux bisphosphonates dont l’efficacite est contrebalancee par une observance mediocre a long terme. Un seul anabolisant osseux est actuellement commercialise, le teriparatide (fragment 1–34 de la parathormone recombinante), qui, sous la forme d’une injection sous-cutanee quotidienne, stimule les deux versants du remodelage osseux au profit de la formation osseuse. L’anticorps antisclerostine, en neutralisant un antagoniste de la voie de signalisation Wnt (promotrice de l’activite des osteoblastes) repond au challenge de la mise au point d’un anabolisant osseux n’augmentant pas la resorption osseuse. Si la tolerance de ces traitements prometteurs est bonne dans les essais cliniques de duree limitee, leur implication dans des voies de signalisation interessant differents tissus doit rendre vigilant sur leurs risques potentiels a long terme. Enfin, il convient de mentionner, pour que l’endocrinologue y trouve son interet, que les facteurs locaux de regulation du remodelage osseux recemment identifies (sclerostine, osteoprotegerine…) semblent etre les mediateurs cles des hormones a tropisme osseux.

ObjectiveTurner's syndrome (TS) is well known, but prognosis for 45,X/46,XX mosaicism below 30% of aneuploidy has not been established. We evaluated differences in clinical features and biological parameters between patients with numerical sex chromosome mosaicism diagnosed incidentally and control women.DesignRetrospective observational study of clinical features and biological parameters.MethodsStandard endocrinological and gynecological examination was done and early-follicular-phase blood values were collected from the medical records of women aged 21–43, who were referred to our ward from 1996 to 2006 because of infertility and were karyotyped. Seventy-one women with sex chromosome mosaicism (45,X/46,XX) ranging from 4 to 28% were assigned a chromosomally normal woman (46,XX) matched according to age (n=71).ResultsIn group 45,X/46,XX, 8% or more of aneuploidy accounted for a smaller height compared to controls (P=0.01). Body mass index was increased from 6% of aneuploidy (P=0.02) and was positively correlated to the percentage of 45,X cells (P=0.0001); menarche occurred earlier from 10% of aneuploidy (P=0.01) and was inversely correlated to the percentage of 45,X cells (P=0.045). No difference was found between the groups for FSH, LH, estradiol, inhibin B, and TSH values. Spontaneous abortions were more frequent in case of mosaicism (P=0.01), and recurrence was positively correlated to the percentage of aneuploidy (P=0.008).ConclusionSex chromosome mosaicism is responsible for clinical changes from 6% of aneuploidy, corresponding to the main phenotypical features of TS.

Resume La frequence et la gravite du diabete de l’hemochromatose sont en relation directe avec le degre et sans doute la duree de la surcharge en fer. Le diagnostic et le traitement adaptes et precoces de la surcharge en fer sont essentiels dans la prevention des consequences cliniques de l’hemochromatose, et en particulier du diabete dont la frequence a deja nettement diminue. Les mecanismes physiopathologiques permettant d’expliquer le diabete de l’hemochromatose associent essentiellement une atteinte de l’insulinosecretion et, plus tardivement, une insulinoresistance aggravee par une atteinte hepatique eventuelle. Le traitement du diabete de l’hemochromatose est non different de la pratique habituelle en diabetologie : dietetique, activite physique et traitement par hypoglycemiants oraux, puis par insuline lorsque l’insulinopenie est manifeste. La surveillance de l’hemoglobine A1c (HbA1c) est perturbee par les saignees. Le meilleur traitement est preventif par les saignees precoces, d’ou l’interet du depistage de l’hemochromatose dans les familles a risque.

Pregnancy is an immunological paradox that implies that a semi-allogeneic fetus is not rejected by the maternal immune system, from implantation of the embryo to delivery. Progesterone (P4), estradiol (E2) and human chorionic gonadotropin (hCG), contribute to the transformation of immune cells in a transient tolerance state, necessary to the maintenance of pregnancy. The effects of pregnancy hormones depend probably of their maternal plasma level. hCG is dangerous at high concentrations because it can stimulate autoantibodies production, whereas in physiological concentrations, hCG, P4 and E2 upregulate immune response expanding regulatory T and B cells, allowing the fetus to grow within the maternal uterus in a protective environment. A second example of fetal-maternal relation found recently is the role of maternal nutrition on development of the fetal hypothalamic neurons. Experiments in mice fed on a high fat diet reveal a critical timing when altered maternal metabolism affect formation of hypothalamic neurocircuits of the offspring and predispose him to long-term metabolic disorders.

Summary Objective Self monitoring of blood glucose (SMBG) in type 2 diabetes is a topic of current interest (imbalance between increased health-care costs and improvement in compliance with treatment and diet). An open label randomized prospective study was designed to compare changes in metabolic control over 6 months in patients managed with usual recommendations alone (conventional assessment group) or combined with SMBG. Research design and methods Patients not treated with insulin or previously self monitored, 40 to 75 years of age, with a diagnosis of type 2 diabetes > 1 year and standardized HbA 1c level ≥ 7.5 and ≤ 11% were randomized to either a control group or SMBG group. They were followed up every 6 weeks over 24 weeks. Patients in the SMBG group were given the same device (Ascensia Esprit® Discmeter, Bayer) and were required to perform at least 6 capillary assays a week (3 different days of the week, including weekend). Management of patients was standardized, including drugs, diet and physical activity. The primary efficacy criterion was change in HbA 1c level in Intent To Treat (ITT) patients. Assays were performed at baseline, at 3 and 6 months using the calibrated DCA 2000® device (Bayer). Results Two hundred sixty five general practitioners randomized 988 patients (ITT Population), but 689 patients were evaluable for the primary criterion. At the endpoint, HbA 1c was lower in the SMBG group (8.1 ± 1.6%) than in the conventional treatment group (8.4 ± 1.4%, P = 0.012). The change in HbA 1c levels between baseline and endpoint was classified into two classes: improvement if a change > 0.5% occurred, stability or worsening in case of a change ≤ 0.5%; 57.1% of patients in the SMBG group vs 46.8% in the control group had an improvement in HbA 1c level ( P = 0.007) after 3 months. A steady state was reached during the last 3 months. A multivariate logistic regression analysis was performed and identified factors predictive of improvement in HbA 1c levels: HbA 1c at baseline: odd ratio (OR) = 1.749 ( P P = 0.015), duration of diabetes: OR=0.953 ( P = 0.001) and BMI: OR=0.962 ( P = 0.039). Conclusions This study is the first multicenter, controlled, prospective trial conducted on a large number of patients demonstrating that SMBG was statistically associated with a better quality of metabolic control than usual traditional recommendations alone in type 2 diabetes.

Today, primary hyperparathyroidism (PHPT) is frequently diagnosed at an asymptomatic stage. New international guidelines presented at the Endocrine Society congress update the management of this disease. Normocalcemic PHPT is part of the diagnostic spectrum of PHPT, its natural history is poorly known, and monitoring is proposed once secondary HPT has been eliminated. Bone involvement, classically predominant in cortical bone, also affects trabecular bone. Osteodensitometry is poorly effective at the vertebral level and new methods (trabecular bone score [TBS], vertebral fracture assessment [VFA]) should improve the assessment of the risk of fracture. The kidney is the most frequently symptomatic organ, and an imaging workup as well as urinary tests are recommended in all patients when searching for causes of lithiasis or nephrocalcinosis. More than 10% of PHPT cases are related to a germinal mutation: these patients should be identified to optimize their management and that of their relatives. Medical treatment is reserved for patients for whom surgery is not indicated or possible: cinacalcet is effective for calcemia, the bisphosphonates are effective for bone involvement. Vitamin D deficiency can be corrected as long as calcemia and creatinuria are monitored. Surgical treatment is recommended in case of pronounced hypercalcemia, bone or renal involvement, and age less than 50 years and in patients in whom monitoring is refused or impossible. Studies have shown that asymptomatic PHPT evolves little in monitored patients.

Diabetes & Metabolism - In Press.Proof corrected by the author Available online since jeudi 31 octobre 2013

International audience; The silent pheochromocytoma, a hidden form of pheochromocytoma, exposes the patient to an increased risk of mortality if the diagnosis is not established on time. Biological diagnosis of pheochromocytoma can be difficult. Catecholamine secretion is dependent on tumor size and a large number of physiological, pharmacological, lifestyle modifications and sampling conditions influence the measurement of urinary and plasma metanephrines. The prevalence of pheochromocytoma is 2% among adrenal incidentaloma smaller than 3 cm (2/3 of tumors). Recent studies suggest the almost zero risk of pheochromocytoma among these tumors if they are hypodense (

Objective Several studies have shown an increased frequency of chromosomal aberrations in female partners of couples examined prior to intracytoplasmic sperm injection (ICSI). A retrospective cohort study was performed to determine whether 45,X/46,XX mosaicism affects the outcomes of in vitro fertilization (IVF) or ICSI. Study design Forty-six women with a 45,X/46,XX karyotype with 6–28% of aneuploidy were compared with 59 control women (46,XX), matched for age, from the female population who underwent IVF or ICSI between 1 January 1996 and 31 December 2006 at the Reproductive Medicine Unit at Brest University Hospital. The outcomes of 254 treatment cycles were compared according to patient karyotype. Results No difference was found in the number of retrieved oocytes (8.9 ± 5.5 vs 8.5 ± 4.7; p = 0.56) or the number of mature oocytes (7.4 ± 4.7 vs 6.9 ± 4.2; p = 0.49) between the 45,X/46,XX group and the 46,XX group, respectively. Fertilization rates did not differ between the groups for either IVF or ICSI. In addition, no difference was found in the pregnancy rate by cycle (17.4% vs 18.7%, respectively; p = 0.87). The percentage of first-trimester miscarriages was similar in both groups (13.6% vs 12.5%, respectively; p = 0.51). Conclusion 45,X/46,XX mosaicism with 6–28% of aneuploidy has no adverse effect on the outcomes of IVF or ICSI among women referred to assisted reproductive technologies.

International audience; Women who had gestational diabetes must have their glycemia closely checked after delivery to insure complete normalization. Few studies are published but breast feeding does not seem to modify the metabolic profile of the mother or the children. Contraception must take account associated risk factors. Very few studies are published and none notified a significant modification of the carbohydrate metabolism with hormonal contraception, either estroprogestative or progestative only. But associated obesity, hypertension or dyslipidemia need the prescription of a contraception with no vascular secondary effect. In these cases an intrauterine device represents a very good choice.

Introduction D'apres Donnan, le diabete est responsable de readmissions plus frequentes et de sejours hospitaliers plus longs. En 2010, une Unite Mobile d'Education au Diabete a ete mise en place afin d'ameliorer la prise en charge des patients diabetiques hospitalises hors service de diabetologie. Le but de notre etude est d'evaluer l'impact de l'UMED sur la DMS et le nombre de patients rehospitalises dans la population de diabetiques hospitalises en cardiologie pour SCA en 2013, selon que les patients aient ete vus ou non par l'UMED et de comparer ces donnees a celles d'une population de diabetiques hospitalises pour SCA en 2009 (avant l'UMED). Materiels et Methodes A partir des donnees issues du codage, tous les patients diabetiques hospitalises pour un SCA en 2009 (65 patients) et 2013 (111 patients : 35 vus par l'UMED et 76 non vus par l'UMED) ont ete inclus avec recueil de la DMS et du nombre de rehospitalisations. Resultats La DMS n'a pas ete differente entre les patients de 2013, qu'ils aient ete vus ou non par l'UMED, ni entre les patients de 2009 et 2013. Le delai moyen [demande d'intervention de l'UMED – date entree hospitalisation] etait de 7,5 jours pour une DMS moyenne de 9,7 jours. Les patients vus par l'UMED etaient plus jeunes (63,8 vs 72,6 ans) et presentaient davantage de decouverte de diabete (22,9 vs 4,7 %) ou une hemoglobine glyquee plus haute (7,8 vs 7 %). Le taux de rehospitalisations n'etait pas significativement different entre les trois populations. Conclusions Dans cette population, nous n'avons pas mis en evidence de difference significative sur la DMS et le nombre de rehospitalisations depuis la mise en place de l'UMED, mais durant l'hospitalisation, les services font appel a nous tardivement. Il nous parait important de sensibiliser nos collegues cardiologues pour une prise en charge precoce des patients diabetiques par l'UMED.

Introduction L'insuline est un des medicaments injectables le plus frequemment impliques dans les erreurs liees aux soins et fait partie des 10 « Never Events » Les erreurs liees a l'insuline durant l'hospitalisation surviennent au cours des differentes etapes du circuit du medicament. L'objectif est d'evaluer les pratiques professionnelles concernant les conditions de stockage et d'utilisation des stylos a l'insuline dans les services de soins du CHRU. Materiels et Methodes 135 unites (MCO/SSR/SANTE MENTALE/EPHAD) ont participe a un l'audit detention et stockage concernant la gestion des insulines en juin 2015. Nous avons utilise comme referentiel les recommandations de l'OMEDIT Bretagne. Les items de la grille de recueil comprenaient l'utilisation des stylos, le stockage avant ouverture, le respect des conditions apres ouverture, l'utilisation conforme du stylo avec usage des aiguilles securisees. Resultats 49 unites (36,8 %) utilisaient des stylos a insuline le jour de l'audit. Avant ouverture, les conditions de stockage etaient satisfaisantes (100 % des insulines au refrigerateur). Apres ouverture, la condition « 1 stylo = 1 patient » etait respectee dans 75,5 % des cas mais sur les 218 stylos ouverts en cours d'utilisation dans les services, seuls 121 stylos (55,5 %) comportaient une etiquette d'identification du patient apposee sur le corps du stylo. La date limite apres ouverture n'etait notee que dans 10,2 % des cas. Les aiguilles securisees etaient utilisees dans 63,2 % des cas. La consigne « Pas de prelevement d'insuline a l'aide d'une seringue dans le stylo » n'etait pas respectee dans 44,4 % des services. Conclusions Cet audit a mis en evidence de mauvaises pratiques concernant en particulier le respect de l'identification des stylos a insuline et l'utilisation de ces stylos. Le prelevement a l'aide de seringues dans les stylos est d'autant plus dangereux que sont commercialisees des insulines plus concentrees. Nous menons actuellement une campagne d'amelioration des pratiques concernant l'usage des stylos a insuline qui necessitera une nouvelle evaluation des pratiques.

Oral manifestations of endocrine dysfunction often may be observed initially by the dentist. Objective manifestations, such as ophtalmos in hyperthyroidism, signs of hypersecretion of GH in acromegaly, are easily recognized. Dentists should have some knowledge of many other diseases in this category that occasionally come in our attention. The present article will discuss the effects of over and under-secretion of each endocrine gland separately, showing its influence on the development and maintenance of the health of the teeth and supporting structures. Diabetes mellitus is the most common endocrinological disease, with an incidence of 3%. Periodontitis risk is three time greater in diabetic patients than in general population and it may worsen the diabetes evolution. Periodontitis in diabetic patients needs an rapid diagnosis and treatment. We also presents the oral aspects of thyroid, parathyroid, suprarenalian, growth hormone and female hormones pathology. The incidence of these troubles is less important, but oral manifestations may reveal an endocrine disfunction.

Acromegaly favours the development of extrapituitary neoplasms presumably promoted through increased GH and IGF-I levels. We describe here two patients which acromegaly and benign and malignant melanocytic tumours of the eye choroid. The first patient had a 15 year history of progressive acromegaly despite trans-sphenoidal surgery, radiation and bromocriptine therapy when she presented with melanoma of the eye and a contralateral benign melanocytic tumour. The second patient was referred with typical acromegaly. The initial fundal examination revealed a right sided benign melanocytic tumour of the choroid. Subsequent follow up of the naevi has not shown any change in the tumours after one and three years respectively. The occurrence of melanoma has not been reported in acromegaly. Increased growth of benign naevi might be expected as GH and IGF-I receptors have been described on melanocytes. As naevi may degenerate into melanomas in normal subjects and radiation therapy could trigger their transformation, we suggest that prior to irradiation, acromegalic subjects should undergo a careful ocular examination in order to assess the presence of ocular naevi.

Introduction Les donnees medicales des patients du reseau Diabiroise sont enregistrees depuis 2005 (959 bilans retournes depuis 2005). Au moins un bilan a ete retourne pour 518 patients, soit 52 % des patients. Les resultats sont compares a ceux d’ENTRED echantillon 2007–2010. Patients et methodes Caracteristiques des patients : Diabete de type 2 principalement (90 %), âge moyen : 63,4 +/− 11,3 ans ; sex ratio : 0,52 H/F ; poids moyen : 84,6 +/− 17,8 kg, IMC > 30 chez 55 % des patients (41 % dans ENTRED) ; 76 % de patients hypertendus dont 44 % avaient une PA controlee (130/80). Observations Le taux moyen des HbA1c passe de 7,33 % en 2005 (n = 163) a 6,92 % en 2009 (n = 757). Le % de patients ayant une HbA1c 8 % passent sous ce taux ; 33 % des patients ayant une HbA1c entre 7 et 8 % passent sous 7 % ; 88 % des patients ayant une HbA1c 7 % ont beneficie d’une mesure de changement : traitement majore, consultation diabetologique, hospitalisation. Conclusion Conclusions : Sur 518 des 912 patients adherents en juin 2010, le reseau diabiroise apporte des donnees objectives sur l’amelioration de l’equilibre glycemique, la qualite de la surveillance selon les referentiels existants, le traitement des facteurs de risque, la lutte contre l’inertie therapeutique, la collaboration entre medecin traitant et diabetologue.

Objectif Decrire la prise en charge diagnostique, therapeutique et le pronostic a un an des osteites du pied chez les patients diabetiques au CHU de Brestentre 2006 et 2008. Materiels et methodes Etude retrospective de 31 infections osseuses concernant 20 patients. Le diagnostic d’osteite est base sur l’existence de criteres cliniques d’infection associes a – des criteres bacteriologiques d’infection (prelevements osseux et/ou cutanes et/ou hemocultures) – et/ou des criteres radiologiques d’infection osseuse. Un echec est defini par l’absence de cicatrisation de la plaie un an apres la fin de l’antibiotherapie ou par une amputation quelque soit son niveau. La guerison est definie par l’absence d’echec 1 an apres la fin de l’antibiotherapie Resultats L’âge moyen est de 65,6 ans. La duree moyenne du diabete est de 17,2 ans. Un contact osseux, un mal perforant plantaire et une collection sont retrouves dans respectivement 48,4 %, 54,8 % et 32,3 % des cas. Sur les prelevements (27 osseux, 24 cutanes et 4 hemocultures), les cocci a Gram positif sont retrouves dans 61,4 % des cas dont 43,9 % de staphylocoques (7 % de SARM) et les bacilles a gram negatif dans 33,3 % des cas. Aucune bacterie anaerobie n’est retrouvee. Une antibiotherapie est instauree pour 30 osteites. 19 actes chirurgicaux orthopediques sont realises (4 actes de mise a plat et 15 amputations). Une chirurgie vasculaire est realisee dans 4 cas. Un an apres l’arret des antibiotiques, 12 osteites sont considerees gueries Conclusion Les caracteristiques generales et la repartition des micro-organismes sont semblables a celles rapportees dans la litterature avec cependant un pourcentage de SARM et de bacteries anaerobies inferieur. L’utilisation d’un milieu de transport (Rosenow) devrait ameliorer la detection de ces dernieres. Si les amputations dites mineures font partie de la guerison, comme souvent dans la litterature, notre taux de guerison s’eleve de 39 a 68 %.

Kinetics of the 2- and 4-hydroxylations of estradiol (E2) by human liver microsomal samples were studied to determine the major P450 isoform involved in these endogenous reactions. Thirty human liver microsomal samples were analysed. Metabolism of 25 microM [14C]E2 produced 2-hydroxy and 4-hydroxy derivatives with a ratio of 3.2 +/- 1.5 and a great inter-individual variation. Kinetic analysis of the 2- and 4-hydroxylations of E2 exhibited a curvilinear double reciprocal plot with an apparent Km of 15 microM. Further experiments demonstrated that alpha-naphthoflavone, testosterone and progesterone increased the 2-hydroxylation activity, suggesting the involvement of a substrate activation mechanism. These two hydroxylations of E2 were shown to be catalysed by cytochrome P450 with an apparent dissociation constant Ks of 0.8 microM. These 2- and 4-hydroxylations inter-correlated significantly (r = 0.93; N = 30). The 2-hydroxylation of E2 correlated with four monooxygenase activities known to be supported by P450 3A4/3A5, namely nifedipine oxidation (r = 0.78; N = 29); erythromycin N-demethylation (r = 0.69; N = 27), testosterone 6 beta-hydroxylation (r = 0.66; N = 25) and tamoxifen N-demethylation (r = 0.64; N = 29). On the other hand, E2-hydroxylations did not correlate with activities supported by P450 1A2 and P450 2E1. Furthermore, drugs as cyclosporin, diltiazem, triacetyl-oleandomycin and 17 alpha-ethynylestradiol inhibited more than 90% of the E2-hydroxylations at concentrations < 250 microM, while weak inhibition was shown with 500 microM cimetidine and no significant inhibition with caffeine, phenacetin and omeprazole. Finally, 2- and 4-hydroxylations of E2 correlated significantly with the content of P450 3A4/3A5 immunodetected by a monoclonal antibody anti-human P450-nifedipine (r = 0.84; N = 28). E2-hydroxylation activities were inhibited by more than 80% with polyclonal anti-human anti-P450-nifedipine. Preincubation of human liver microsomes with 100 microM gestodene (a suicide substrate of P450 3A4) inactivated this P450 isoform and accordingly allowed evaluation of the contribution of other P450 isoforms to the E2 metabolism to about 21% (+/- 17%, N = 29). All these results taken together suggest that P450 3A4/3A5 are the major forms involved in the formation of catecholestrogens in the human liver microsomes.

Objectifs pedagogiques Savoir que la prevalence de l’hyperaldos-teronisme primaire est sous-estimee chez l’hypertendu. Connaitre les indications, les techniques et les risques du catheterisme veineux surrenalien dans l’hyperaldosteronisme primaire. Savoir que la tomodensitometrie seule est insuffisante pour poser une indication therapeutique dans le cadre d’un hyperaldosteronisme primaire. Messages a retenir La tomodensitometrie a une excellente sensibilite pour la detection d’un adenome mais ne peut pas affirmer sa responsabilite dans l’hypersecretion d’aldosterone. Il est indispensable de confirmer ou d’infirmer cette hypersecretion par la realisation de dosages hormonaux par prelevements veineux selectifs. Le catheterisme veineux surrenalien permet de determiner le caractere unilateral (adenome) ou bilateral (hyperplasie surrenalienne) de cette hypersecretion et de determiner la therapeutique la plus adaptee (chirurgicale ou medicale). Le catheterisme veineux necessite une bonne connaissance de l’ana-tomie normale des veines surrenaliennes et de ses variantes.

Objectif Nous avons recueilli les donnees medicales annuelles des patients adherents du reseau Diabiroise a partir des fiches de bilans annuels. Au moins un bilan a ete retourne pour 177 patients. Nous avons compare nos resultats avec ceux de l'etude ENTRED Bretagne 2003. Resultats Les caracteristiques de nos patients etaient : âge moyen : 65±10 ans ; sex-ratio : 0,53 Hommes/femmes ; poids moyen : 84,9±17,5kg ; obesite : 54 % versus 42,5 % (ENTRED) ; 65 % de patients hypertendus (55 % ayant une tension controlee). HbA1c moyenne : 7,2 % sur 557 valeurs enregistrees. Le % de patients dont l'HbA1c etait superieure a 8 % semble diminuer avec le temps : 27 % en 2005, 19 % en 2006, 14 % en 2007. On constate une augmentation dans le temps de la proportion de patients dont l'HbA1c est inferieure a 7 % (49 % vs 53 %, ns). 16 % des patients avaient une retinopathie diabetique contre 10 % dans ENTRED. La microalbuminurie etait presente chez 28 % des patients (ENTRED 25 %). 81 % des patients microalbuminuriques etaient sous IEC ou sartans. 80 % des patients ont beneficie d'une gradation podologique. Les grades 2 (25 %) ont beneficie du forfait podologique. 44 patients (25 %) avaient un haut risque cardio-vasculaire * *defini selon recommandations de l'HAS de 2006. dont 77 % etaient sous statines et 82 % sous antiagregants. 77 patients (43,5 %) etaient sous insuline. 91 % des patients sous insuline ou sous insulino-secreteurs pratiquaient l'autosurveillance glycemique. Conclusion Les reseaux ne selectionnent pas les patients les plus « faciles » mais bien ceux porteurs des complications du diabete. Ils obtiennent un meilleur suivi des recommandations a travers des protocoles cooperatifs, le decloisonnement des pratiques et l'education d'un patient mieux implique dans sa prise en charge. Ceci en fait des appuis precieux aux medecins traitants pour organiser le parcours de soins.