[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.

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.

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.

Testicular adrenal rest tumours in young adult males with congenital adrenal hyperplasia: prevalence and impact on testicular function

Testicular adrenal rest tumours (TARTs) have been described in patients with congenital adrenal hyperplasia (CAH). The aim of the study was to determine the prevalence of TARTs in patients with CAH, the associated factors and their impact on gonadal function. It is a prospective study concerning six young adult men with CAH, four cases with 21-hydroxylase deficiency and two cases with 11-hydroxylase deficiency. All patients were under glucocorticoid therapy. The mean age was 25 years (range: 20-31). All patients underwent a physical examination with testicular palpation, scrotal ultrasonography, a blood sample for serum testosterone, FSH, LH, inhibin B, ∆4-androstenedione and 17-OH-progesterone measurements and a semen analysis. Ultrasound revealed TARTs in four patients; three were bilateral. The mean tumour size was 6.3 ml (range: 0.02-14.1). The tumours were palpable in two cases. 17-OH-progesterone was <10 ng/ml in all cases. Decreased testosterone level was found in one case. The semen analysis revealed azoospermia in one case and poor semen quality in four patients. TARTs were common and associated with impaired spermatogenesis.

[McCune-Albright syndrome associated with diabetes mellitus]

McCune-Albright syndrome (MAS) consists of the triad of polyostotic fibrous dysplasia, cutaneous pigmentation, and multiple endocrine abnormalities. Type 1 diabetes mellitus is not included in MAS. We report the case of an 18-year-old girl who presented with McCune-Albright syndrome. The diagnosis was made by the presence of precocious puberty at the age of 6 years, cutaneous pigmentation, polyostotic fibrous dysplasia, and phosphate diabetes. Type 1 diabetes mellitus developed at the age of 16 years. We discuss this case, the relationship between type 1 diabetes mellitus and MAS, with a literature review.

[Diverticulum of the left atrium detected antenatally. Management of a case]

Cardiac diverticulae are rare, most often affecting the ventricles rather than the atria. We report the case of a diverticulum of the left atrium discovered during routine fetal echocardiography. The diagnosis was confirmed at birth with cardiac echography and an MRI. In view of the patient's age and asymptomatic nature, it was decided to defer surgery and to observe the infant with regular echocardiography. Surgery was eventually performed via a left thoracotomy after the appearance of signs of cardiac compression, and there were no complications in the post-operative period.

[Revascularization of the lower limbs with extra-anatomic shunts. Report of 80 cases]

The extra anatomical bypasses are those which do not follow the usual arterial pathway. The aim of this study is to define the indication of extra anatomical bypasses and to compare them with other revascularisation procedures. In this paper we report a retrospective study carried between January 1988 and December 1999 involving 80 patients (78 men and 2 women) who underwent extra anatomical bypasses for revascularisation of their lower limbs (83 bypasses). The mean age of the patients was 62 years. The indication for revascularisation was chronic arteritis of the lower limbs in 72 patients (90%), infected aneurysms in 6 cases (7.5%) and acute aortic dissection in 2 cases (2.5%). We performed an axillo-unifemoral bypass in 23 cases, an axillo-bifemoral in 17, a crossover ilio-femoral or femoro-femoral bypass in 41 cases, and 2 transobturator ilio popliteal bypass right and left in 1 case. Hospital mortality rate was 10%. Hospital morbidity was about 65%. Limb salvage was 78%. Sixty patients were regularly followed during a mean follow-up of 31 months. Late mortality was 10%. In the end of our study global limb salvage rate was 74%.

IN CONCLUSION

extra-anatomical revascularization allows acceptable limb salvage rate along with lower operative risk even in poor state patients.

[Role of surgery in subaortic stenosis. Report of 56 cases]

INTRODUCTION

Subaortic stenosis is a rare congenital heart disease defined as a left ventricular outflow tract obstruction. We reviewed our surgical experience in this cardiac disease with particularly attention to the different anatomical types of the obstruction.

PATIENTS AND METHODS

From January 1987 to December 1998, 56 patients with a mean age of 12.4 years underwent surgical treatment of subaortic stenosis in our Institution. The diagnosis included: subaortic membrane in 44 cases, fibromuscular process in seven and tunnel like hypertrophy in five.

RESULTS

There were two hospital deaths (2/56 = 3.5%) and three patients presented postoperative heart block. The first postoperative echocardiographic control showed a mean fall in left ventricleaorta gradient of 78%. In a mean follow-up of 36 months, there were no deaths. All patients periodically controlled, showed an echocardiographic progression of the gradient and it was not related to the different anatomical types of the obstruction. There were no signs of aortic insufficiency progression.

CONCLUSION

We can affirm that the surgical treatment of the subaortic obstruction is simple and safe. The medium and long-term progression toward the recurrence is independent to the anatomical type and justify the need of serial echocardiographic control.

Predictive risk factors for deterioration from normoglycemic state to type 2 diabetes mellitus or impaired glucose tolerance in a Tunisian urban population

OBJECTIVE

To determine the predictive risk factors for the development of type 2 diabetes mellitus (DM) or impaired glucose tolerance (IGT) in a normoglycemic population.

RESEARCH DESIGN AND METHODS

This is a ten-year prospective study in a randomly selected urban population including 1835 subjects aged >=30 years living in Tunis, 1460 were normoglycemic according to 2 hours blood glucose WHO criteria, and 701 among them attended the follow-up assessment ten years later. Subjects with impaired glucose tolerance (IGT) were excluded. Subjects underwent a physical examination including weight/height, iliac circumference (IC) and blood pressure measurements. Fasting and 2-hour venous blood sampling, after a 75 g oral glucose load, were performed for the measurement of plasma glucose (G(0), G(2h)), insulin (I(0), I(2h)), total cholesterol (TC) and glycated hemoglobin (HbA(1c)) levels.

RESULTS

Out of the 701 normoglycemic subjects in 1985, 77 developed diabetes and 130 impaired glucose tolerance after 10 years, giving a mean annual incidence rate of 1.1% for diabetes and 1.85% for IGT. Univariate analysis showed that risk factors for diabetes were age, BMI, IC, SBP, G(0) and total cholesterol in both sexes, I(0) and I(2h) in men only and DBP G(2h) and HbA(1c) in women only. Risk factors for IGT were BMI, IC and G(2h) in both sexes, I(2h) in men only and G(0) in women only. Multivariate analysis revealed that BMI, G(0) and G(2h) were independent risk factors for conversion to diabetes or IGT in both sexes, but HbA(1c) and IC were risk factors only in men.

CONCLUSION

Early screening and prevention of diabetes must focus on obese subjects, especially those with central fat distribution, and those with moderate increase in fasting and/or two-hour blood glucose levels within the normal range.

[Perforated gastroduodenal ulcers. Treatment by peritoneal dialysis. 72 cases]

Seventy-two perforated gastroduodenal ulcers were treated by an original method aimed at avoiding emergency surgery, which consists of peritoneal dialysis associated, during 3 days, with gastric aspiration. Over a 3-year period this method was applied to all patients admitted with a perforated ulcer. The ulcer was revealed by the perforation in 25 p. 100 of the cases, and 90 p. 100 of the patients had pneumoperitoneum. Contrast radiography with Gastrografine (sodium and meglumine amidotrizoate) located the perforation. Fifteen patients had another disease which made the prognosis worse. The time elapsed between perforation and treatment was 15 hours on average. Peritoneal fluid infection was present in 30 p. 100 of the cases. The outcome was favourable in 69 patients (96 p. 100). One patient died of pulmonary embolism, another was operated upon on the 4 th post-perforation day for a bleeding ulcer and a third patient with giant gastric ulcer developed subphrenic abscess. This method seems to be indicated in patients at high surgical risk (elderly people or people with severe underlying disease), and in young patients with perforated acute ulcer. In chronic ulcers, peritoneal dialysis ties the patient over the first hours, thus enabling radical surgery to be electively performed. In perforations seen after 24 hours, it helps in supporting the patient prior to surgery. The method in contra-indicated in gastric ulcers.