Effects of high-intensity statin therapy on steroid hormones and vitamin D in type 2 diabetic men: A prospective self-controlled study

The study aimed to assess the effect of high-intensity statin therapy on testicular and adrenal steroids and vitamin D levels in type 2 diabetic men. A prospective study, conducted between March 2021 and July 2022, including 60 men with type 2 diabetes, aged 40-65 years, statin-free, and in whom treatment with high-intensity statin was indicated. The patients had two visits, before and 6 months after a daily intake of 40 mg of atorvastatin. During each visit, they underwent a clinical examination, and a fasting blood sample was collected for biological and hormonal measurements. There was a significant increase in the prevalence of decreased libido (from 22% to 47%, p = 0.001) and a significant decrease in the frequency of sexual intercourse (from 4 [1-8] to 3 [0-4] per month, p = 0.005). The median ADAM's score significantly increased (from 4 [2-7] to 6 [3-8], p = 0.000). Twenty-two percent of the patients developed gynecomastia. The median total, bioavailable and free testosterone significantly decreased from 15.1 (11.4-17.4), 6.3 (5.0-7.8), and 0.27 (0.22-0.33) nmol/L to 12.7 (10.7-15.9), 5.7 (4.4-7.0), and 0.24 (0.19-0.30) nmol/L, respectively, with no change in FSH and LH levels. Three patients (5%) developed hypogonadism (testosterone <8 nmol/L). There was a significant decrease in DHEAS from 4.5 (2.8-6.1) to 3.8 μmol/L (2.6-5.6) and no change in cortisol and vitamin D levels. High-intensity statin therapy decreased androgen levels in type 2 diabetic men with significant clinical impact.

Long-term complications of permanent hypoparathyroidism in adults: prevalence and associated factors

INTRODUCTION

Patients with Chronic hypoparathyroidism (CHPT) receiving conventional treatment are exposed to several long-term complications including basal ganglia calcifications, posterior subcapsular cataract, kidney stones, and renal insufficiency. The aim of this study was to assess the prevalence and the associated factors of these complications in patients with CHPT.

METHODS

We conducted a cross-sectional study including 58 patients with CHPT. All participants underwent physical examination, biochemical assessment (total serum calcium, serum phosphorus, serum albumin, intact-PTH, serum magnesium, 25-hydroxy-vitamin D, serum creatinine, thyroid stimulating hormone (TSH), and 24-hour urinary calcium), slit lamp examination, brain computed tomography scan (CT-scan), and renal ultrasound.

RESULTS

Participants had a mean age of 52.6 ± 16.4 years and a gender ratio (women/men) of 3.5. Fahr syndrome, cataract, urolithiasis, and renal failure were found in 55%, 62%, 12%, and 17% of cases, respectively. CHPT duration >15 years (Adjusted-OR = 43.1, 95-CI: 2.63-703.06, p = 0.008) and poor adherence to treatment (Adjusted-OR = 8.04, 95%-CI: 1.52-42.42, p = 0.014) were independently associated with the risk of Fahr syndrome. Age >55 years (adjusted-OR = 5.07, 95-CI: 1.10-23.42, p = 0.037), disease duration >15 years (adjusted-OR = 20.21, 95-CI: 1.54-265.84, p = 0.022), and magnesium level <0.8 mmol/l (adjusted-OR = 36.46, 95-CI: 3.75-354.08, p = 0.002) were independently associated with the risk of subcapsular cataract. Only hypercalciuria (Adjusted-OR = 21.27, 95-CI: 2.31-195.91, p = 0.007) was an independent risk factor for kidney stones. Renal failure was not associated with kidney stones (p = 1). However, creatinine clearance was negatively correlated with age (r = -0.784; p < 10-3) and disease duration (r = -0.352; p = 0.007).

CONCLUSION

Our results revealed high prevalences of neurological, ocular, and renal complications in patients with CHPT and emphasized the importance of regular biological monitoring, therapeutic adjustments, screening, and adherence to treatment in the prevention of these complications.

Salivary Cortisol Measurement Contamination After Oral Hydrocortisone: A Randomized Crossover Trial

The study aimed to evaluate salivary cortisol (SC) contamination and determine the associated factors in secondary adrenal insufficiency (SAI) patients treated with hydrocortisone (Hc). A randomized crossover trial involved SAI patients. SC was measured before the morning Hc dose, then at one, two, and four hours after. The procedure was performed twice on two days of a week: one day while taking Hc in tablet form (tablet set) and one day while taking Hc in capsule form (capsule set). Area under the curve (AUC) of SC levels over time was calculated in each participant for the two sets. SC contamination was defined as AUCtablet above the 95th percentile of AUCcapsule. Thirty-four patients (24 females and 10 males) with a median age of 48 years were enrolled. Post-Hc dose SC levels were higher in tablet than in capsule set, particularly at one hour. Prevalence and extent of SC contamination were estimated to 32% and 88%, respectively. In capsule set, SC measured two hours after Hc intake showed the strongest correlation with AUC (r=0.88, p<0.001). In multivariate analysis, serum potassium≥3.9 mEq/l was the only predictor for SC contamination [multi-adjusted OR (95% CI): 7.1 (1.4-36.1); p=0.018]. SC measured during the two hours after Hc intake is inaccurate for glucocorticoid replacement therapy assessment in SAI patients treated with Hc in tablet form.

Assessment of quality of life in patients with permanent hypoparathyroidism receiving conventional treatment

Introduction

Patients with permanent hypoparathyroidism suffer from multiple complaints and are exposed to long-term complications that might compromise their well-being. The aim of this study was to assess the quality of life (QoL) in patients with permanent hypoparathyroidism receiving conventional therapy and to determine the associated factors.

Methods

This was a cross-sectional matched case-control study including 53 patients with permanent hypoparathyroidism and 53 matched controls. Biochemical blood parameters (calcium, phosphate, albumin, magnesium, 25-hydroxy-vitamin D, creatinine, TSH, and PTH) and 24-hours calciuria were measured in patients with hypoparathyroidism. QoL was assessed in all participants using the Short Form 36 Health Survey (SF-36).

Results

The study included 53 patients (41 women and 12 men) with hypoparathyroidism receiving conventional therapy.Their mean age was 52.8 ± 16.5 years. In comparison with controls, patients with hypoparathyroidism had significantly lower scores in all eight domains of SF-36 (p < 10- 3). Patients with poor socioeconomic conditions had lower SF-36 scores than those with good conditions.The etiology of hypoparathyroidism, the disease duration, the control of the disease, and the body mass index did not significantly interfere with SF-36 scores. SF-36 total score was negatively correlated with age (r=-0.619, p < 10- 3) and symptoms of hypocalcemia (r=-0.284, p = 0.039), and positively correlated with creatinine clearance (r = 0.559, p < 10- 3), magnesium level (r = 0.345, p = 0.011), and 25 hydroxy-vitamin D level (r = 320, p = 0.021). No significant correlations were found between SF-36 scores and other biological parameters such as calcemia, phosphatemia, phosphocalcic product, PTH, TSH, and calciuria.

Conclusion

Patients with permanent hypoparathyroidism had impairment in their QoL. Age, socioeconomic conditions, renal function, magnesium level, and 25 hydroxy-vitamin D level may interfere in the decline of the QoL of these patients.

Adherence to glucocorticoid replacement therapy in Addison's disease: Association with patients' disease knowledge and quality of life

Little is known about the quality of adherence to glucocorticoid replacement therapy in patients with Addison disease (AD). The aim of this study was to evaluate the quality of glucocorticoid treatment adherence in patients with AD and to assess its association with patients' disease knowledge and quality of life.

METHODS

This is a cross-sectional study including 58 patients with AD. The Girerd questionnaire was used to assess the quality of adherence to glucocorticoid replacement therapy. A questionnaire was specially designed to assess patients' disease knowledge. The AddiQol questionnaire, specific to AD, was used to assess the patients' quality of life. Patients were considered non-adherent if they gave three or fewer than three negative answers to the Girerd questionnaire (score≤3/6).

RESULTS

The mean age of the patients was 48.4±13.3 years (39 women and 19 men). Twenty-seven patients (46%) were non-adherent to glucocorticoid replacement therapy. An age below 48 years, poor adherence to comorbidity treatments, baseline cortisolemia at diagnosis>5μg/dl, history of adrenal crisis, poor knowledge about the disease, BMI<26.7kg/m2, waist circumference<90cm, low systolic blood pressure, fasting blood glucose<0.9g/l, and triglyceride<1g/l were the factors independently associated with non-adherence (respectively ORa [CI 95%]=4.8 [2.8-10.7], 5.0 [3.0-12.2], 2.3 [1.2-6.2], 4.1 [2.0-8.3], 3.9 [1.2-7.2], 3.9 [1.1-6.9], 1.8 [1.1-2.9], 4.8 [2.6-8.2], 2.5 [1.1-5.3], and 2.2 [1.1-5.1]). There was a positive correlation between the disease knowledge questionnaire score and the Girerd score (p=0.02, r=0.31). There was a positive correlation between the AddiQoL score and the Girerd score (p=0.01, r=0.32).

CONCLUSION

Non-adherence to glucocorticoid replacement therapy was common in patients with AD and was associated with more frequent adrenal crisis and poorer quality of life. The quality of treatment adherence was correlated with patients' disease knowledge. Therapeutic education is essential to reduce the frequency of non-adherence, especially among young patients.

Spontaneous bladder rupture after non-traumatic vaginal delivery: a rare case report

Spontaneous bladder rupture (SBR) is a rare condition and often missed diagnosis, especially after a non traumatic vaginal delivery. A 32-year-old para 3 woman, consulted for abdominal pain and anuria two days after instrumental vaginal delivery with forceps for foetal distress in second sate of labour. Blood tests were suggestive of an acute renal failure. An abdominocentesis revealed a clear fluid looking like ascites. The ultrasound and computed tomography (CT) scan showed a large abdominal effusion. An exploratory laparoscopy revealed a bladder perforation which was sutured after laparotomy. SRB is extremely rare after a non traumatic vaginal delivery. It is associated with significant morbidity and mortality. Symptoms are mostly non-specific. It is suspected when post partum abdominal pain is associated with an effusion and renal failure signs. If suspected, the uroscanner remains the gold standard for diagnostic. Laparotomy is the standard surgical approach in this condition. Abdominal pain with elevated serum creatinine should be suspicious of SBR in post-partum.

Metabolic disorders during endogenous Cushing's syndrome: prevalence, associated factors, and outcome after remission

Objective. The prognosis of Cushing's syndrome (CS) is related to a higher cardiovascular morbidity and mortality. This study aimed to determine the prevalence of metabolic disorders in patients with CS, the associated factors, and the rate of remission of these disorders after the remission from CS. Methods. It is a retrospective study including 75 cases of CS followed up at the university hospital La Rabta of Tunis from 1987 to 2018. Clinical and paraclinical data were collected from medical files. Results. The mean age of the patients was 44.1±18.9 years and the sex ratio was 0.39. At CS diagnosis, the frequencies of obesity, hypertension, diabetes, dyslipidemia, and metabolic syndrome were 52, 75, 43, 83, and 73%, respectively. The age, gender, body mass index, waist circumference, and baseline serum cortisol level were not associated with the presence of diabetes, hypertension or dyslipidemia. Forty-eight patients were operated on. At one year, 38 patients were in remission from CS. The remission rates of hypertension, diabetes, and dyslipidemia were respectively 58% (p<0.001), 76% (p<0.001), and 17% (NS). Conclusion. Metabolic disorders were frequent during CS and their frequencies decreased after the remission from the syndrome.

Anti Mullerian hormone as a diagnostic tool for polycystic ovary syndrome in women of reproductive age with morbid obesity

OBJECTIVES

The aim of the study was to analyze the performance of the anti-mullerian hormone (AMH) level for the diagnosis of polycystic ovary syndrome in women with morbid obesity.

STUDY DESIGN

A single-centre cross-sectional study was conducted in 50 women of reproductive age with a body mass index (BMI) ≥ 40 kg/m². Each patient underwent a clinical examination, biological and hormonal assays, and an ovarian ultrasound between the third and the fifth day of the menstrual cycle. Polycystic ovary syndrome was diagnosed according to the Rotterdam's criteria.

RESULTS

The mean age of participants was 34.2 ± 7.5 years. Polycystic ovary syndrome was diagnosed in 20 women (40%). Age and anthropometric parameters did not differ between women with and without polycystic ovary syndrome. The mean AMH level was significantly higher in women with polycystic ovary syndrome (3.4 ± 3.6 vs 1.3 ± 1.2 ng/ml, p=0.010). It was positively correlated with the Ferriman and Gallwey score (r=0.496, p=0.016), total testosterone level (r=0.524, p < 10^-3) and the LH/FSH ratio (r=0.290, p=0.046). In women aged between 35 and 45 years, the optimum cut-off level for the diagnosis of polycystic ovary syndrome was 0.81 ng/mL, providing a sensitivity and a specificity of 90 and 71%, respectively with an area under the ROC curve of 0.857.

CONCLUSIONS

AMH level was significantly higher in morbid obese women with polycystic ovary syndrome compared with those without polycystic ovary syndrome. Specific thresholds for this population must be assessed to improve the sensitivity and specificity of AMH for the diagnosis of polycystic ovary syndrome.

Thyroid hormone resistance syndrome caused by a novel mutation in the thyroid hormone receptor‐beta gene ( THRB , GLU457LYS ) treated with methimazole

A 15‐year‐old girl presented with hyperactivity and behavior disorders. She had tachycardia and no goiter. Thyroid hormones were high and TSH normal. A novel mutation GLU457LYS in THRB gene was observed. Methimazole and propranolol improved clinical symptoms but increased TSH level.

Elevated thyroid hormones without a decrease in TSH suggests two diagnoses: thyroid hormone resistance and TSH secreting pituitary adenoma. THRB, GLU457LYS is a novel mutation of the thyroid hormone receptor and was expressed with thyrotoxicosis, short stature with no goiter. Methimazole induced clinical improvement but an increase of TSH level.

A case of Hashimoto's thyroiditis following Graves' disease

Graves' disease is characterized by the presence of circulating autoantibodies that stimulate the TSH receptor, inducing hyperthyroidism and goiter. Hashimoto's thyroiditis is an autoimmune disease leading to thyroid tissue destruction by cell and antibody-mediated immune processes. The occurrence of Hashimoto's thyroiditis following Graves' disease has been rarely reported. Its pathogenesis is not clear. Herein, we report the case of a 40-year-old woman who was referred to our department for thyrotoxicosis. Laboratory tests revealed overt hyperthyroidism. Thyroid scintigraphy showed an enlarged gland with diffusely increased tracer uptake, confirming the diagnosis of Graves's disease. The patient was treated with propranolol and thiamazole. Two months later, she received radioactive iodine therapy. Three years and 9 months later, the patient presented with hypothyroidism and very high levels of thyroperoxidase antibodies consistent with the diagnosis of Hashimoto's thyroiditis. She was treated with levothyroxine. The shift from Graves' disease to Hashimoto's thyroiditis was reported in the literature. However, its pathogenesis has not been clearly elucidated.

Management of severe hypercalcaemia secondary to primary hyperparathyroidism: The efficacy of saline hydration, furosemide, and zoledronic acid

INTRODUCTION

Severe hypercalcaemia is a life-threatening condition that should be managed urgently. The aim of this study was to assess the efficacy of saline hydration, furosemide, and zoledronic acid in the management of severe hypercalcaemia secondary to primary hyperparathyroidism (PHPT).

METHODS

We conducted a retrospective analysis of the management of 65 patients with severe hypercalcaemia (≥3 mmol/L) secondary to PHPT. The efficacy of each therapeutic agent was evaluated according to the variation in serum calcium level calculated as Δ calcium = initial calcium level - minimal calcium level reached after the administration of each agent.

RESULTS

The mean age of patients was 56.4 ± 13.8 years. At baseline, the mean total serum calcium level was 3.42 ± 0.40 mmol/L. After normal saline hydration, calcium level decreased from 3.25 ± 0.21 to 2.98 ± 0.2 mmol/L (p < 10^-3 ) in 3.1 ± 1.7 days. Normalization of calcium level did not occur in any patient. Furosemide was prescribed in 35 patients. It resulted in a serum calcium increase of 0.09 ± 0.21 mmol/L. Calcium levels did not reach the normal range in any patient. Forty-five patients received intravenous zoledronic acid. The mean maximal reduction in serum calcium level was 0.57 ± 0.27 mmol/L (from 3.25 ± 0.26 mmol/L to 2.68 ± 0.22 mmol/L, p-value <10^-3 ). Normalization of calcium levels occurred in 27 patients (60%).

CONCLUSIONS

Our results show the absence of a significant additional effect of furosemide on calcium levels in patients with severe hypercalcaemia secondary to PHPT when compared with the effect of saline hydration alone. However, zoledronic acid was more potent. Thus, appropriate normal saline hydration with immediate intravenous bisphosphonates infusion should be considered in the management of severe hypercalcaemia in patients with PHPT.

Diabetic patient satisfaction on the quality of outpatient health care services

AIM

To assess the degree of satisfaction of diabetic patients with health care services and to determine the factors that influence it.

METHODS

It was a cross sectional study conducted in 2018 among diabetic outpatients of the department of endocrinology of the university hospital La Rabta. Patients general characteristics were noted. Each patient responded to a questionnaire, asked orally, in Tunisian dialect, by two physicians, about health care services including 20 questions grouped into three items. Each question was scored from 1 to 4 according to the degree of satisfaction. The global score as well as the scores of the items were calculated by adding the scores of the corresponding questions.

RESULTS

150 diabetic patients responded to the questionnaire; mean age: 58.9±12.2 years [18-88], sex-ratio: 0.51. Cronbach coefficient was 0.78. The overall score was 62.2±6.5 [46-80]. Ninety-seven patients (64.7%) had a score ≥60. The item concerning 'human contact and communication' was considered good in 98% of cases. The item concerning 'premises, cleanliness, comfort and safety' was considered intermediate in 64% of cases. Patients were very satisfied with the accessibility of the department inside the hospital (76.7%), the attitude of the agents during the administrative formalities (74%) and particularly the behaviour of the doctor (96%). However, they were dissatisfied with the noise (72%) and overcrowding (67.4%) of the waiting room. There were no statistically significant associations between the overall score and the studied data.

CONCLUSION

The diabetic patients were overall satisfied with the provided services. Actions must be taken to reduce overcrowding and long waiting times.

Management of patients with cardiovascular diseases during Ramadan

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

The remission phase in adolescents and young adults with newly diagnosed type 1 diabetes mellitus: prevalence, predicting factors and glycemic control during follow-up

Objective

There is little data about the remission phase in adolescents and young adults with newly diagnosed type 1 diabetes mellitus (T1D). The aims of this study were to determine the prevalence of remission and its predicting factors among adolescents and young adults with newly diagnosed T1D and to assess the association between remission and long-term glycemic control in this population.

Methods

This is a longitudinal and retrospective study including 128 type 1 diabetic patients aged between 12 and 30 years at diabetes onset. Clinical, biological and therapeutic features were collected at diagnosis and for 5 years after diagnosis. Remission was defined by an HbA1c < 6.5% with a daily insulin dose < 0.5 IU/kg/day.

Results

Twenty-three patients (18%) experienced a remission. The peak of remission prevalence was at 6 months after diabetes diagnosis. An insulin dose at discharge <0.8 IU/kg/day was independently associated with remission (p=0.03, adjusted OR [CI 95%] = 0.2 [0.1-0.9]). A low socioeconomic level was independently associated with non remission (p=0.02, adjusted OR [CI 95%] = 4.3 [1.3-14.3]). HbA1c was significantly lower during the first five years of follow-up in remitters. The daily insulin dose was significantly lower during the first four years of follow-up in remitters.

Conclusion

Occurrence of remission in adolescents and young adults with newly diagnosed T1D is associated with better glycemic control and lower insulin requirements during the first 5 years of follow-up. A lower initial dose of insulin was associated with a higher percentage of remission.

Professional practices in the management of adrenal insufficiency in two tertiary referral hospitals (Tunis, Tunisia)

BACKGROUND

Adrenal insufficiency (AI) is a rare and life-threatening disease. Glucocorticoid replacement therapy and patient education are crucial. Few is known about physician practice in this topic.

AIMS

To describe physician practice in the management of AI and to identify the associated factors.

METHODS

the physicians, all grades and specialties, from two university hospitals in Tunis, were invited to respond to a paper-based 16- multiple choice item-questionnaire about the management of AI and the prevention of acute AI. Each question was scored 1 if correct or 0 if incorrect. The global score was calculated by adding the score of the first 15 questions.

RESULTS

200 physicians responded to the questionnaire, sex ratio: 0.47, mean age: 29.0 ± 5.8 years (24 - 60). The overall rate of correct answers was 59.6%. The rate of correct responses was good for the type of replacement therapy (92%), the lifelong duration of treatment (88%), the symptoms of overtreatment (73.5%), the type of diet indicated (77%), and the necessity of special measures during the peri operative period (100%). However, the rate of correct responses was low for the half-life of hydrocortisone (12.5%), biological signs suggesting acute AI (17.5%), situations during which an increase in the dose of glucocorticoid is required (26.5%) and the risks of intermittent fasting (2%). Endocrinology specialty and overall medical specialties were independently associated with a better global score.

CONCLUSION

physician practice in the management of AI need to be improved.

Interest of the waist-to-height ratio to predict metabolic syndrome in type 2 diabetic patients

INTRODUCTION

Metabolic syndrome (MetS) is defined as a cluster of risk factors for cardiovascular disease.

AIM

To determine the optimal cut-off point of the waist-to-height ratio (WHtR) at which MetS can be identified with maximum sensitivity and specificity in a sample of Tunisian type 2 diabetic patients.

METHODS

We enrolled 457 type 2 diabetic patients in a cross-sectional study. Blood pressure, anthropometric indices, fasting glucose, and lipid profile were measured. WHtR was calculated. MetS was defined according to the IDF criteria. Receiver operating characteristic (ROC) curve analysis was used to identify the optimal cut-off value of WHtR in MetS screening with maximum sensitivity and specificity.

RESULTS

The overall prevalence of MetS was 79.8%, it was higher in women than in men (85.5% vs 61.4%; p.

Predictive factors for recurrence of Cushing's disease after pituitary surgery

INTRODUCTION

The first-line treatment for Cushing's disease (CD) is transsphenoidal excision of the corticotropic adenoma.

AIM

To identify the predictive factors of recurrence of corticotropic adenomas after pituitary surgery.

METHODS

This is a retrospective and longitudinal study conducted in 28 patients operated for corticotropic adenoma between 1987 and 2014 and followed up in the department of endocrinology of La Rabta Hospital in Tunis (Tunisia). The mean duration of follow-up was 82 ± 65.9 months. The population was subdivided into two groups according to the occurrence or not of a recurrence. Recurrence was defined by hormonally confirmed postoperative recurrence of Cushing's syndrome.

RESULTS

The mean age of the patients was 30.8±11.8 years (24 women and 4 men). CD was related to a microadenoma in 46% of cases (n=13) and a macroadenoma in 54% of cases (n=15). The recurrence rate was 28% (n=8/28). The mean time to diagnosis of recurrence was 5.6±4 years. The sex ratio (F/M) was 7 in the recurrence group (R) and 5.6 in the non-recurrence group (NR); p= NS. The mean age of patients in the (R) group was 27.2±11.8 years and 32.2±11.9 years in the (NR) group; p= NS. The recurrence rate was 63% in case of macroadenoma and 37% in case of microadenoma; p= NS. Postoperative cortisolemia was significantly higher in the recurrence group (23.2 ± 13.5 µg/dl vs 4.4 ± 3.9 µg/dl; p 4.4 µg/dl was significantly associated with recurrence (100% vs 26.3%; p= 0.001). The duration of corticotropic axis inertia was 67.2 ± 47.7 months in the (R) group versus 88.37 ± 72.14 months in the (NR) group; p= NS.

CONCLUSIONS

Nearly a quarter of patients operated for CD develop a recurrence within five years. A postoperative cortisol level > 4.4 µg/dl is predictive of disease recurrence. Multicenter studies and a larger sample are needed to support these results.

[Risk factors for major lower limb amputations in diabetic patients hospitalized for diabetic foot ulcer]

BACKGROUND

Amputations in diabetes patient lead to high postoperative morbidity and mortality .

AIM

To indentify the risk factors for major lower limb amputations in diabetic patients hospitalized in endocrinology department.

METHODS

It was a descriptive retrospective study including diabetic patients hospitalized in the endocrinology department of the Rabta Hospital for management of an infected foot lesion. We distributed the patients into 2 groups: group 1: patients with major amputation of the lower limb and group 2: patients who have had an amputation below the ankle or who had a conservative treatment.

RESULTS

One hundred and twenty patients were included. The mean age was 59 ±11.9 years [28-97]. Twenty one (17.5%) patients had a major amputation (group 1). The frequency of obliterating arterial disease and gangrenes of the lower limbs were significantly higher in group 1. The extent of lesions> 2cm and the frequency of osteitis were comparable between the two groups. The frequency of hyperleukocytosis and mean C reactive protein were significantly higher in group 1. Antibiotic therapy prescribed during hospitalization was targeted in 30% of cases in group 1 versus 12.9% in group 2 (p = 0.05). Obliterating arterial disease, gangrenes and long duration of diabetes were independant risk factors significant on binary regression analysis.

CONCLUSION

Some risk factors associated with major amputations are modifiable, such as arteriopathy obliterating of the lower limbs. A larger and prospective study would allow a better analysis of the predictive factors of major amputations.

Intermittent fasting in adrenal insufficiency patients: a review and guidelines for practice

Ramadan fasting is a religious duty for adult Muslims. Even though sick people are exempted from fasting, numerous are those who insist on fasting, and seek advice from their physicians. The role of the physician is to support his patient and preserve his health. However, little is known about intermittent fasting in adrenal insufficiency. The aim of this review was to determine the risks of fasting in patients with adrenal insufficiency, the subjects at risk of complications, and the measures that can be undertaken for safe fasting. The analysis of the data of the different studies showed that there is a risk of complications during fasting in these patients. Optimal glucocorticoid replacement therapy for safe fasting has not yet been determined. Finally, a risk stratification and the modalities of the pre-Ramadan visit for adrenal insufficiency fasting patients have been suggested.

A diffuse large B-cell thyroid lymphoma presented as a compressive goiter in a young woman with no evidence of Hashimoto's thyroiditis

Thyroid lymphoma should be suspected in case of rapid enlargement of the thyroid gland even in a young patient with no history of Hashimoto thyroiditis. The confirmation is based on histopathology and immunohistochemistry.

Assessment of quality of life in adult type 1 diabetic patients

INTRODUCTION

Few studies have examined the quality of life (QOL) of type 1 diabetic patients (T1D) in adulthood and its association with glycemic control.

AIMS

To assess the QOL of a Tunisian population of T1D adults and to identify the factors that may influence it.

METHODS

It's a cross-sectional study including 100 T1D patients over 18 years of age whose QOL was assessed by the ADDQOL scale. A multivariate logistic regression analysis was performed to identify the factors independently associated with impaired QOL.

RESULTS

The QOL score without diabetes was -1.5±0.7 indicating that patients' QOL would be better without diabetes. Factors associated with impaired QOL were age≥33 years (p=0.011), poor socioeconomic status (p=0.01),  longer-lasting diabetes (p=0.007), lower daily insulin dose (p=0.001), human insulin-based treatment (p=0.049), higher prevalence of hospitalization for ketoacidosis (p=0.003) and infectious complication (p=0.008), higher incidence of hypoglycemia (p=0.003), higher prevalence of nephropathy (p=0.029) and diabetic retinopathy (p=0.038), higher HbA1c level (p=0.031) and irregular follow-up (p=0.021). According to multivariate analysis poor glycemic control (HbA1 ≥ 9.3%) and lower insulin dose (<0.84IU/Kg/d) were independently associated with impaired QOL.

CONCLUSION

There is an association between glycemic control and QOL in T1D patients in adulthood, prompting us to consider this parameter in the management of T1D patients.

Salivary cortisol levels during Ramadan fasting in hydrocortisone-treated secondary adrenal insufficiency patients

OBJECTIVE

Patients with adrenal insufficiency have difficulties in fasting during the month of Ramadan with an increased risk of complications. Cortisol levels are unknown in these patients. The objective of this study was to assess the daily cortisol profile in hydrocortisone-treated patients with secondary adrenal insufficiency (SAI) and healthy controls during a fasting day.

METHODS

A cross-sectional matched case-control study on 50 hydrocortisone-treated SAI patients and 69 controls who are used to fast. Clinical and therapeutic data were collected. Five salivary samples for cortisol measurement were collected throughout a fasting day of the third week of Ramadan 2019.

RESULTS

Salivary cortisol levels were significantly higher on awakening, at midnight and before the predawn meal in patients compared with controls. The circadian cortisol rhythm was disrupted in patients. The area under the salivary cortisol level versus time curve (AUC) was lower than the 2.5th percentile of the controls in one patient (2.5%) and higher than the 97.5th percentile in 23 patients (59%) who were considered overtreated. Age ≥ 35 years was independently associated with overtreatment (adjusted odds ratio = 12.0; 95% CI (2.0-70.4); p = 0.006). Seven patients broke their fasting for a complication compared with no one of the controls (p = 0.001). No factor was associated with this risk.

CONCLUSIONS

Salivary cortisol levels were high in fasting hydrocortisone-treated SAI patients with a disruption of the circadian rhythm.

Blood pressure evaluated by 24 h ambulatory blood pressure monitoring in Ramadan-fasting patients with corticotrope deficiency

PURPOSE

The risks of Ramadan fasting on blood pressure (BP) in patients with adrenal insufficiency are unknown. This study aimed to evaluate the levels of BP and particularly the risk for hypotension during a fasting day compared with a nonfasting day in patients with corticotrope deficiency.

METHODS

A prospective case-crossover study on 28 patients with known and treated corticotrope deficiency who were fasting the month of Ramadan. Clinical (eating and sleeping habits, abnormal symptoms, weight, height, and BP) and paraclinical (creatinine, sodium, and cortisol) data were collected. Patients had a 24 h ambulatory BP monitoring during a Ramadan fasting day then again during a nonfasting day.

RESULTS

The data of 25 patients were analyzed; 20 women, median age: 40 years (IQR, 22.5-45.5), median duration of the disease: 6 years (IQR, 2.5-12). The prevalence of hypotension did not differ between the fasting day and the nonfasting day. Hour by hour BP levels comparison showed that both systolic and diastolic BP were significantly lower at 2.00 p.m. during fasting. BP variability was significantly lower during the fasting period compared with the same period during the nonfasting day.

CONCLUSIONS

Fasting was not associated with an increased risk for hypotension in patients with known and treated corticotrope deficiency.

Prednisolone or hydrocortisone replacement in patients with corticotrope deficiency fasting during Ramadan result in similar risks of complications and quality of life: a randomized double-blind controlled trial

PURPOSE

The aims of the study were to compare the risk of complications and the quality of life in patients with corticotrope deficiency, who fasted during Ramadan. Both hydrocortisone and prednisolone were compared as treatments.

METHODS

A randomized double-blind crossover clinical trial conducted in the department of Endocrinology of the University Hospital la Rabta in Tunis, during Ramadan 2018, on 53 patients with known corticotrope deficiency treated with hydrocortisone 20 mg per day and who were willing to fast during Ramadan. Patients were randomized into two groups; AB that received hydrocortisone twice daily for 14 days then prednisolone once daily with a placebo for 14 days and group BA that received the two treatments in the reverse order. Patients had to complete a daily follow-up sheet about their eating and sleeping habits, the occurrence of complications and blood glucose monitoring and also to respond to the AddiQoL questionnaire at the end of each treatment period.

RESULTS

Fifty patients' data were analyzed; 29 men, mean age: 42.4 ± 13.3 years, mean duration of the disease: 8.1 ± 7.6 years. The frequency of complications, mean blood glucose levels and the quality of life did not differ on hydrocortisone compared to prednisolone after adjustment for the sequence of the treatment.

CONCLUSIONS

the risks of Ramadan fasting in patients with corticotrope deficiency were the same on hydrocortisone or prednisolone.

Cardiothyreosis: Prevalence and risk factors

Cardiothyreosis (CT) or thyrotoxic heart disease is associated with higher morbidity and mortality than the other forms of hyperthyroidism. Its risk factors have been analyzed in a limited number of studies. The aims of our study were to investigate the prevalence of CT and its risk factors in patients with hyperthyroidism.

METHODS

We identified 538 patients with a hospital discharge diagnosis of hyperthyroidism from January 2000 to December 2015. Among them, 35 patients were diagnosed as having CT. Their demographic, clinical and biological characteristics were studied and compared with those of 72 controls (patients admitted for hyperthyroidism without CT) randomly selected using univariate and multivariate analysis.

RESULTS

The prevalence of CT in patients hospitalized with overt hyperthyroidism was 6.5%. The cardiac complications seen were atrial fibrillation (AF) in 33 cases (6.1%) and cardiac heart failure (CHF) in 11 cases (2%). The risk factors of CT were age greater than 50 years (OR=13.1; 95% CI [4.9-34.4]), low socioeconomic status (OR=2.8; 95% CI [1.2-6.7]), low educational level (OR=3.1; 95% CI [1.2-8.3]), personal history of hypertension (OR=3.5; 95% CI [1.1-11.2]) and a multinodular toxic goiter as the etiology of hyperthyroidism (OR=4.6; 95% CI [1.6-13.9]). After multivariate analysis, age greater than 50 years was the only independent risk factor of CT (adjusted OR=11.6; 95% CI [2.7-49.5]). Severe biological hyperthyroidism (FT4 >3 times normal) was associated with a lower risk of CT (adjusted OR=0.2; 95% CI [0.1-0.9]).

CONCLUSIONS

The prevalence of CT in patients with overt hyperthyroidism was relatively low. Cardiac complications were AF and CHF with a clear predominance of AF. Advanced age was the only independent risk factor of CT. Cardiac complications may be seen even if hyperthyroidism is not biologically severe.

Pituitary tuberculosis presented with pituitary coma

BACKGROUND

Pituitary tuberculosis is very rare. Its diagnosis is difficult unless a bacteriological or histological evidence of tuberculosis.

OBSERVATION

We report the case of a 54 years old woman who presented with a pituitary coma that occurred two weeks after the initiation of antituberculous therapy for cervical lymph node tuberculosis. Resonance magnetic imaging showed a pseudotumoral aspect of the pituitary gland. She had hormonal replacement and anti-tuberculous therapy. Outcome was favourable with the normalization of both the pituitary function and the pituitary volume. However, an acute hypopituitarism happened eight months after the withdrawal of antituberculous, which were taken during 12 months. The re initiation of anti tuberculous therapy and its extension to two years leaded to a prolonged remission.

CONCLUSION

the three-phase outcome confirms the tuberculous origin of the hypophysitis in our patient.

The risk for hypoglycemia during Ramadan fasting in patients with adrenal insufficiency

OBJECTIVES

The risk for hypoglycemia during Ramadan fasting in patients with adrenal insufficiency (AI) is not fully known. The aims of this study were to evaluate this risk objectively and to determine the associated factors.

METHODS

This prospective case-crossover study included 25 women and 5 men with known and treated AI and a median age of 38.5 y. Patients underwent clinical examination and a fasting blood sample was collected to measure glucose, urea, creatinine, sodium, potassium, cortisol, growth hormone and free thyroxine. A 24-h continuous glucose monitoring system (CGMS) using iPro2 (Medtronic, Parsippany, NJ, USA) with Enlite sensor (Medtronic) was performed for each patient during a Ramadan fasting day then again during a nonfasting day.

RESULTS

Interstitial glucose levels during the 24-h period, the fasting period, and the fasting period after exclusion of the 5 postprandial hours were significantly lower during the fasting day than on the nonfasting day. Hypoglycemia occurred in three patients (10%) during the fasting day but not during the nonfasting day (P = 0.23). Hypoglycemia was asymptomatic in two cases. Male sex was significantly associated with the occurrence of hypoglycemia.

CONCLUSION

Interstitial glucose levels were lower during fasting in patients with AI. However, the risk for hypoglycemia was not increased.

Insulin-induced edema: an unusual complication in a patient with diabetic ketosis

The insulin-induced edema is a rare complication of insulin therapy. Two mechanisms are known, the sodium and water retention and vasoactive mediator's release. We report the case of a 32 years-old patient, with a history of diabetes for one month treated with metformin. He was hospitalized for diabetic ketosis and developed lower legs edema and scrotum edema, few hours after the insulin injections. Biologic tests showed hypoprotidemia without proteinuria and hyponatremia. The abdominal ultrasound showed a liver steatosis. Chest radiography was normal. Transthoracic echocardiography showed a moderate pericardial effusion. Edema resolved spontaneously one month later. Protidemia and natremia were normalized. The natural history of insulin-induced oedema was observed in our patient and the accountability of insulin is likely, but invetstigations are often needed to eliminate other causes of edemas.

Ramadan fasting in patients with adrenal insufficiency

AIM

The risks of fasting during Ramadan in patients with adrenal insufficiency are unknown. The aims of this study were to evaluate these risks in such patients, to determine the risk factors and finally to set some recommendations.

METHODS

It is a cross-sectional study about 180 patients with known and treated adrenal insufficiency. The patients responded to a 14-item questionnaire concerning their knowledge about the disease and fasting during the last month of Ramadan.

RESULTS

There were 132 women and 48 men. The mean age was 47.6 ± 15.0 years (14-79). One hundred and thirty eight patients (76.7 %) were advised by their physician not to fast. Ninety-one patients (50.5 %) tried to fast. Complications occurred in 61 cases (67.0 %): asthenia in 88.5 % of cases, intense thirst in 32.8 %, symptoms of dehydration in 49.2 % and symptoms of hypoglycaemia in 18 %. One patient was hospitalized. Fifty-five patients (60.4 %) were able to fast for the whole month. Age, gender, duration of the disease, its primary origin, associated hypothyroidism, diabetes mellitus, hypertension or diabetes insipidus and daily dose of hydrocortisone did not significantly differ between fasters and non-fasters, full-month-fasters and partial-month-fasters, and fasters with complications and fasters without complications. The frequency of adequate knowledge about the disease was significantly higher in full-month-fasters vs. partial-month-fasters, and in fasters without complications vs. those with complications.

CONCLUSION

In patients with adrenal insufficiency, fasting can cause complications especially if the level of knowledge about the disease is low.

Bone Mineral Density in Sheehan's Syndrome; Prevalence of Low Bone Mass and Associated Factors

Hypopituitarism is a known cause of bone mineral loss. This study aimed to evaluate the frequency of osteopenia and osteoporosis in patients with Sheehan's syndrome (SS) and to determine the risk factors. This is a retrospective study of 60 cases of SS that have had a bone mineral density (BMD) measurement. Clinical, biological, and therapeutic data were collected. The parameters of osteodensitometry at the femoral neck and the lumbar spine of 60 patients with SS were compared with those of 60 age-, height-, and weight-matched control women. The mean age at BMD measurement was 49.4 ± 9.9 yr (range: 25-76 yr). The mean duration of SS was 19.3 ± 8.5 yr (range: 3-41 yr). All patients had corticotropin deficiency and were treated with hydrocortisone at a mean daily dose of 26.3 ± 4.1 mg. Fifty-seven patients (95%) had thyrotropin deficiency and were treated with thyroxine at a mean daily dose of 124.3 ± 47.4 µg. Thirty-five of the 49 patients, aged less than 50 yr at diagnosis and having gonadotropin deficiency (71.4%), had estrogen-progesterone substitution. Osteopenia was present in 25 patients (41.7%) and osteoporosis in 21 (35.0%). The BMD was significantly lower in the group with SS than in the control group (p < 0.001). The odds ratio of osteopenia-osteoporosis was 3.1 (95% confidence interval: 1.4-6.8) at the femoral neck and 3.7 (95% confidence interval: 1.7-7.8) at the lumbar spine. The lumbar spine was more frequently affected by low bone mineral mass (p < 0.05). The duration of the disease and the daily dose of hydrocortisone were independently and inversely associated with BMD at the femoral neck. The daily dose of thyroxine was independently and inversely associated with BMD at the lumbar spine. Estrogen-progesterone replacement therapy was not associated with BMD. Low bone mineral mass was very common in patients with SS. The lumbar spine was more frequently affected. The duration of the disease and the doses of hydrocortisone and thyroxine were involved in bone mineral loss.

[Etiological diagnosis of central diabetes insipidus: about 41 cases]

La survenue d'un syndrome polyuro-polydipsiqueavec des urines hypotoniques nécessite une stratégie diagnostique rigoureuse. Le but de cette étude était d’étudier les modalités de diagnostic du diabète insipide central. A travers une étude rétrospective de 41 cas de diabète insipide central(DIC) colligés au service d'Endocrinologie à l'hôpital de la Rabta de Tunis, allant de l'année 1990 à l'an 2013, nous avons relevé les circonstances de découverte du DIC, les anomalies du bilan anté-hypophysaire etde l'imagerie hypophysaire. Le DIC était post opératoire chez 20 patients. La diurèse moyenne de 24 heures était significativement plus élevée chez les patients ayant un DIC en dehors d'un contexte chirurgical. L’épreuve de restriction hydrique était concluante chez tous les patients qui en ont bénéficié. En dehors d'un contexte neurochirurgical, les causes infiltratives étaient retrouvées chez 6 patientset les causes tumorales chez 6 patients. Le DIC était associé à une selle turcique vide dans 1 cas et idiopathique chez 3 malades. L'imagerie par résonnance magnétique hypothalamo-hypophysaire et le bilan anté-hypophysaire sont systématiques en dehors d'un contexte de chirurgie hypophysaire et d'une polydipsie primaire évidente.