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Summary Postprandial hyperglycaemia is a phenomenon often neglected by patients as well as doctors. While patients only voluntarily measure morning and preprandial capillary glycaemia, physicians do not encourage the measurement of anything further. The specific role of postprandial hyperglycaemia in the determination of late diabetes complications, such as micro- and macroangiopathy, remains controversial. It is however undeniable that the postprandial glycaemic excursion plays an important role in total hyperglycaemia reflected by an increase in glycated haemoglobin. The postprandial glycaemia measurement or, more appropriately, the postprandial glycaemic excursion (the difference between postprandial and preprandial glycaemia, also called the postprandial delta glycaemia), is important to measure and there are specific tools to correct it when abnormal. Postprandial delta glycaemia should lie between 30 and 50 mg/dl. It is thus suggested to measure it not necessarily on a daily basis, but when it is expected that the glycaemic couple, or “pre-postprandial couple”, is high. The specific tools for treatment of postprandial hyperglycaemia can be dietetic (carbohydrate quantity reduction or ingestion of fiber-rich and/or low glycaemic index foods) or medicinal. Among the specific medicinal treatments are the alpha-glucosi-dase-inhibitors (which can be used for both type 1 and type 2 diabetic patients), glinides and fast-acting insulins. Rather than first treating fasting and interprandial hyperglycaemia, as has been commonly done by physicians, the authors recommend the simultaneous treatment of pre-, inter- and postprandial hyperglycaemia. The optimal time at which to evaluate postprandial glycaemia is approximately 1 h and 15 minutes for type 1 and type 2 diabetic patients.

Genetic factors could be implicated in the pathogenesis of severe diabetic retinopathy (DR). Recently, we reported a strong association between the eNOS4b/a endothelial nitric oxide synthase (eNOS) polymorphism and severe DR. To examine whether T-786C and C774T eNOS polymorphisms are involved in severe DR, 254 Caucasians with longstanding C-peptide-negative type 1 diabetes, 128 patients with absent/mild DR (control group), and 126 patients with preproliferative/proliferative DR (study group) were genotyped. The distribution of T-786C and C774T eNOS polymorphisms was in Hardy-Weinberg equilibrium and did not differ between the study and control groups. However, in case patients (n=126), T-786C and C774T polymorphisms influenced the onset pattern of severe DR (P=0.0169 and P=0.0257, respectively). The C-786C genotype was associated with early-onset severe DR (duration of diabetes: 15.2+/-5.9 vs. 19.4+/-6.3 years, P=0.0105), and the homozygous T774T genotype was associated with late-onset severe DR (24.3+/-7.0 vs. 18.4+/-6.2 years, P=0.0067). In the case of patients with high glycosylated hemoglobin levels (HbA1c >8%, n=88), the association between the T-786C polymorphism and early-onset severe DR was stronger (P=0.0068). Case patients carrying the C-786C genotype had higher HbA1c values (9.61+/-1.89%) than those carrying the T-786T genotype (8.93+/-1.47%, P=0.0173). Multivariate analysis showed that T-786C polymorphism was the best independent factor for onset pattern of severe DR (P

OBJECTIVE—To determine whether a chronic low-glycemic index (LGI) diet, compared with a high-glycemic index (HGI) diet, has beneficial effects on plasma glucose control, lipid metabolism, total fat mass, and insulin resistance in type 2 diabetic patients. RESEARCH DESIGN AND METHODS—Twelve type 2 diabetic men were randomly allocated to two periods of 4 weeks of an LGI or HGI carbohydrate diet separated by a 4-week washout interval, in a crossover design. RESULTS—The LGI diet induced lower postprandial plasma glucose and insulin profiles and areas under the curve than after the HGI diet. At the end of the two dietary periods, the 7-day dietary records demonstrated equal daily total energy and macronutrient intake. Body weight and total fat mass were comparable. Four-week LGI versus HGI diet induced improvement of fasting plasma glucose (P < 0.01, Δ changes during LGI vs. HGI), HbA1c (P < 0.01), and whole-body glucose utilization measured by the euglycemic-hyperinsulinemic clamp (P < 0.05). LGI diet induced a decrease in fasting plasma total and LDL cholesterol (Δ changes LGI vs. HGI, P < 0.01), free fatty acids (P < 0.01), apolipoprotein B, and plasminogen activator inhibitor 1 activity. CONCLUSIONS—Only 4 weeks of an LGI diet was able to improve glycemic control, glucose utilization, some lipid profiles, and the capacity for fibrinolysis in type 2 diabetes. Even if changes in glycemic control were modest during the 4-week period, the use of an LGI diet in a longer-term manner might play an important role in the treatment and prevention of diabetes and related disorders.

An acute neuropathy rarely occurs early in the course of diabetes mellitus. Five cases are described of adult patients who developed a peripheral neuropathy at the time or shortly after the onset or discovery of diabetes mellitus. Patient 1, an 80-year-old woman who developed a subacute tetraparesis with proximal and distal muscle weakness with normal cranial nerves, proved to have insulin-requiring diabetes mellitus. In the other patients, all men aged 23-34 years, symptomatic neuropathy occurred simultaneously (patient 2) or 1-6 months after the onset of insulin-dependent diabetes mellitus (IDDM) (patients 3-5). Patients 2 and 3 developed a symptomatic multifocal neuropathy; patients 4 and 5, a painful distal symmetrical sensory polyneuropathy (DSSP) shortly after beginning treatment with insulin. Nerve biopsy showed active axonal lesions in patients 2 and 5 and mixed axonal and demyelinating lesions in the others, with severe axon loss in patients 4 and 5. Vasculitic lesions were found in patient 2, who improved without additional treatment. Neurological examination remained unchanged after 2 years in patients 3-5. Although a coincidence cannot be excluded for patients 1-3, whose neuropathy was not of the pattern commonly found in diabetes, it is suggested that acute disequilibrium in the diabetic status may facilitate the occurrence of a variety of neuropathies. Alternatively, the autoimmune process which led to IDDM may also trigger an autoimmune neuropathy with vasculitis (patient 2) or demyelinative nerve lesions. Only the distal symmetrical sensory polyneuropathy with severe axonal lesions observed in patients 4 and 5 seems directly related to diabetes mellitus. In spite of their occurrence shortly after beginning insulin therapy, the role of treatment with insulin in the onset is uncertain.

Proximal diabetic neuropathy is a disabling neuropathy that occurs predominantly in non-insulin-dependent diabetic patients over the age of 50. Inflammatory lesions have been found in nerve biopsy specimens of diabetic patients with severe proximal neuropathy or with other patterns of multifocal neuropathy. Some of these patients respond dramatically to treatment with corticosteroids or with other immunomodulators. In this article we report on our findings in 4 additional patients with painful proximal diabetic neuropathy and different patterns of inflammatory nerve lesions whose condition improved spontaneously shortly after performance of a nerve biopsy, without additional treatment.

The present study assessed 106 diabetic patients 2 years after beginning insulin treatment at or after 70 years of age. Ten patients (9%) had had the therapy discontinued after 2-4 months, 26 (25%) had died of causes unrelated to insulin therapy, 12 (11%) were lost to follow-up, and 58 (55%) were still alive and insulin treated. Fifty-one were at home and seven institutionalized for reasons unrelated to insulin therapy. Of these 58 patients, 50 were available for further study. Except for frequency of travel, which had decreased, lifestyle either improved or did not change. Patients' perceptions of the goals of treatment were more appropriate to a younger population of patients, who are less vulnerable to hypoglycaemic reactions. Mean fasting blood glucose was considered by the medical staff to be too low in 42% of cases. Adding insulin to the treatment of the elderly did not negatively affect their lifestyle, and indeed, insulin therapy appeared to create or strengthen the patients' existing social support network. Educational interventions must attempt to extend the effect of the specialized unit outside the hospital, to families, visiting nurses as well as general practitioners.

Aim This study aimed to assess the prevalence and characteristics of sleep apnoea syndrome (SAS) in patients hospitalized for poorly controlled type 2 diabetes. Methods An overnight ventilatory polygraphic study was systematically performed in 303 consecutive patients. Results Overall, 34% of these patients had mild SAS, as defined by a respiratory disturbance index (RDI) of 5–15; 19% had moderate SAS (RDI: 16–29) and 10% had severe SAS (RDI≥30). The SAS was obstructive in 99% of the apnoeic patients. The percentage of patients with excessive daytime sleepiness (Epworth sleepiness scale>10), fatigue or nocturia did not significantly differ among patients with severe, moderate or mild SAS versus non-apnoeic patients. The percentage of patients who snored was significantly higher in patients with severe or moderate SAS versus non-apnoeic patients. HbA 1c , duration of diabetes and the prevalences of microalbuminuria, retinopathy and peripheral neuropathy did not significantly differ among patients with severe, moderate or mild SAS versus non-apnoeic patients. However, patients with severe or moderate SAS had significantly higher values for body mass index, waist circumference and neck circumference than non-apnoeic patients. Conclusion In type 2 diabetic patients with poor diabetic control, obstructive SAS is highly prevalent and related to abdominal obesity, and should be systematically screened for, as it cannot be predicted by the clinical data.

Objective This study aimed to determine the optimal time to measure peak blood glucose values to find the best approach for self-monitoring blood glucose after a meal. Design and methods For this retrospective analysis, 69 ambulatory continuous glucose-monitoring system (CGMS) profiles were obtained from 75 consecutive insulin-treated patients with diabetes. The parameters measured were the peak post-meal blood glucose values, peak time, and rates of increase and decrease to and from the zenith of the resulting curves. Results The mean peak time after breakfast was 72 ± 23 min, which was reached in less than 90 min in 80% of the patients. The apparent glucose rate of increase from pre-meal to the maximum postprandial value was 1.23 ± 0.76 mg/dL/min, while the glucose rate of decrease was 0.82 ± 0.70 mg/dL/min. Peak time correlated with the amplitude of postprandial excursions, but not with the peak glucose value. Also, peak times were similar after breakfast, lunch and dinner, and in type 1 and type 2 diabetic patients. Conclusion To best assess peak postprandial glucose levels, the optimal time for blood glucose monitoring is about 1 h and 15 min after the start of the meal, albeit with wide interpatient variability. Nevertheless, 80% of post-meal blood glucose peaks were observed at less than 90 min after the start of the meal.

Introduction Le systeme Free Style Libre (FSL) commercialise en France depuis quelques jours pourrait revolutionner l'autosurveillance glycemique. Un capteur applique a l'arriere du bras estime la glycemie a partir du glucose interstitiel. L'exploit technologique reside en une calibration « d'usine » du capteur, sans glycemie capillaire. Outre l'estimation de la glycemie, le sens et vitesse de variation (fleche de tendance) et le profil glycemique des 8 dernieres heures est donne. Les resultats d'etudes randomisees sont attendus pour juin 2015. Nous presentons nos premiers resultats de fiabilite. Patients et methodes Treize patients ambulatoires ont deja ete inclus, tous diabetiques de type 1 [duree 3-45 ans], âges de 20 a 55 ans, sous pompe ( n =6) ou multinjections ( n =7) [HbA1c 6,2 a 8,9 %]. Donnees completes traitees a ce jour sur 8 patients. Methode : differences moyennes et correlation entre glycemies capillaires (SMBG) et FSL en 6 couples quotidiens sur la duree de vie d'un capteur (14 jours). La moitie des couples en preprandial et l'autre en postprandial. Resultats Sur 75 jours d'enregistrement actuellement traites, le coefficient de correlation R2 entre FSL et SMBG est a 0.87, p 0,0001. Equation de la droite y=0.94x + 0. Pas de tendance a la deviation dans les resultats extremes. Analyse grille de Clarke en cours. Dix des 14 capteurs ont fonctionne 14 jours, 1 arret a J4 et 3 autres arraches prematurement. Sept patients sont en cours d'analyse. Un total de 25 patients sera recrute. Conclusion Nos donnees preliminaires sur une cohorte en cours de recrutement suggerent une excellente fiabilite, y compris dans les valeurs extremes. Declaration d’interet Les auteurs declarent avoir un interet avec un organisme prive, industriel ou commercial en relation avec le sujet presente. Abbott : orateur et board .

Diabetes is associated with multiple disorders including metabolic, cellular and blood disturbances leading to vascular complications. Increased circulating levels of platelet-leukocyte aggregates (PLA) have been described in several thrombotic diseases. In this study, we have evaluated circulating PLA in diabetic patients and we have investigated whether they may be a marker of vascular complications. Using flow cytometry assay, we have quantified PLA percentages in 65 diabetics including 20 patients with type I and 45 with type II diabetes, and 25 healthy subjects. Specific labelling identified platelet-polymorphonuclear aggregates (PPA) and platelet-monocyte aggregates (PMA). We have observed a significant increase of PPA and PMA levels in diabetics (22+/-12% and 45+/-18%, respectively) compared to controls (7+/-4% and 19+/-10%, respectively) (p0.01). However, both PPA and PMA values were similar in the two diabetes types. Circulating PPA and PMA were significantly enhanced in diabetics with vascular lesions (PPA: 24+/-13%; PMA: 50+/-18%) than in diabetics without vascular lesions (PPA: 18+/-8%; PMA: 38+/-15%) (p0.05 and p0.01). Patients with PPA18% and/or PMA38% showed a more important vascular injury (OR: 6; 95% CI: 1.6-23). Increased PMA circulating rate is particularly correlated to retinopathic injury (OR: 19; 95% CI: 2.3-154). Our findings established a relationship between increased circulating PLA levels, particularly PMA, and the incidence of microvascular complications in diabetes. They reinforce the concept of pro-inflammatory cells involvement in diabetic retinopathy pathogenesis and their link with thrombotic process.

Increasing postprandial plasma glucose and insulin excursions are assumed to increase severity of diabetes and to be independent predictors of risk for atherosclerotic diseases and adiposity. Many possible connections have been found between postprandial events and the development of diabetes complication [1]. Lowering postprandial plasma glucose and insulin responses is relevant in preventing and managing diabetes mellitus [2,3]. Therefore, intervention towards reducing postprandial plasma glucose and insulin spikes is an essential topic in therapeutic strategy for diabetic patients, and may reduce the risk of developing cardiovascular complications. There is growing recognition that the postprandial glycemic [4,5] and insulinemic [6] responses to different foods may vary despite equal amounts of total absorbable carbohydrates, thus favoring low-glycemic-index (GI) carbohydrates. The notion of glycemic index was proposed by David Jenkins and et al. [5] more than twenty years ago as a practical way of classifying carbohydrate-containing foods according to their effect on postprandial blood glucose rather than according to carbohydrate content alone. The Gl is defined as the incremental area under the blood-glucose response curve of a 50 carbohydrate test food portion expressed as the percentage of the response to the same amount of carbohydrate from standard food (glucose, or white bread) taken by the same subject [7]. In practice, the actual carbohydrate load from a normal portion size varies considerably. Both type and amount of carbohydrate have now widely accepted influences on glycemic response [8,9]. In order to address this problem, the concept of glycemic load (GL) was introduced. GL, calculated as the amount of carbohydrate in one serving multiplied by the GI of the food, allows comparisons between likely glycemic effects of different foods in realistic portions [10]. However, GL values should be considered with caution, as both a low-GI/high-CHO food and a high GI/low-CHO food can have the same GL with different metabolic effects on β-cell function and plasma lipids [8]. Separate use of GL may lead to habitual consumption of low-carbohydrate diets. While short-term beneficial effects could be induced by low-carbohydrate diet, the long-term effects might be harmful. All the centers over the world that have tested experimental and clinical use of low-GI foods are enthusiastic about diet counseling to diabetic or hyperlipidemic patients, and even normal subjects at risk of cardiovascular diseases. A large number of studies have indeed demonstrated the efficiency of diet counseling and the use of low glycemic index (low-GI) foods in these patients. More striking effects were noted in the improvement of postprandial blood glucose excursions and, consequently, in glycated hemoglobin, fasting plasma lipids - particularly triglyceride levels - and, marginally, total and LDL cholesterol. We will give some insights on a few of our clinical and experimental results on this topic. At this stage, we would like to point out that the use of low-GI foods is only part of a more general strategy to improve postprandial hyperglycemia, and thus overall blood glucose control.

There is a large bulk of evidence that using low glycemic index (GI) foods has a very significant impact on the amelioration of metabolic disturbances observed in diabetic and/or hyperlipidemic pati

Introduction Le jeune effectue au cours des programmes d’insulinotherapie fonctionnelle (IF) est une experience unique ou les decisions de resucrage/rajout sont prises dans une situation pure (hors influence des repas, insuline ultrarapide ou activite physique). L’interet educatif est capital, avec validation d’une dose d’insuline basale de jeune, experimentation de l’effet d’un resucrage type ou sensibilite a l’insuline corrective et constatation d’une stabilite glycemique dans ces conditions. Un enregistrement continu de la glycemie a ete effectue. Patients et Methodes Dans le cadre de notre programme d’IF, le jeune calorique total est effectue en ambulatoire avec des consignes d’autosurveillance glycemique et de mesures correctives lorsque les glycemies s’ecartent de la valeur cible [70 a 140 mg/dl]. Nous rapportons le resultat de l’enregistrement continu des glycemies avec ou sans lecture en temps reel, durant 24 h de jeune sous insulinotherapie basale (40 % de la dose totale d’insuline) chez 34 patients. Resultats Tous les patients ont complete le jeune avec 28 enregistrements exploitables. Âges median de 42 ans, 19 ans de diabete, l’HbA1c est a 7,3 % sous pompe (n = 16) ou glargine (n = 11). On observe une stabilisation glycemique pendant la matinee. Le pourcentage de glycemies dans la cible atteint 80 % en fin d’epreuve, sans difference glargine/pompe, mais significativement plus dans le groupe lecture en temps reel de la glycemie avec alarme (p = 0,001). 104 glycemies inferieures a 70 mg/dl ont ete observees, en moyenne 3 par patient, aucune hypoglycemie severe. Vingt cinq pour cent des hypoglycemies n’etaient pas detectes par le moniteur, 27 % n’etaient pas detectes (ou prises en compte) par le patient. Les patients avec lecture directe ont passe moins de temps en hypoglycemie. 22 patients ont eu au moins un episode d’hyperglycemie [>140 mg/dl], pour un total de 31 episodes ayant necessite un rajout d’insuline. Conclusion Le jeune total ambulatoire est possible et sans risque chez le diabetique de type 1, sous reserve d’adaptation de la basale et d’une surveillance glycemique discontinue adaptee. La mesure continue de la glycemie n’est pas indispensable mais permet une analyse plus fine et informative des fluctuations glycemiques et peut-etre plus de confort pour les patients en cas de visualisation directe des glycemies (alarmes).

Introduction L’arrete ministeriel du 17 juillet 2006 cree l’obligation d’une reevaluation annuelle de l’opportunite de la poursuite du traitement par pompe a insuline externe. Nous avons cree une structure et un programme specifique pour repondre a cette exigence. Nous rapportons 5 mois d’experience sur les 87 premiers patients, en presentant specifiquement les donnees recueillies concernant la securite des patients. Patients et methodes Quatre vingt sept patients dont 30 avaient la pompe depuis moins de 6 mois. Anciennete diabete : 22 ans (3-58) et duree de pompe 3 ans (0,16-28). 50 % des patients avaient une retinopathie. Les patients sont accueillis en hopital de jour (HDJ) par un trio infirmiere, dieteticienne, medecin senior. La journee comprend des temps individuels avec chacun des intervenants, une evaluation par auto-questionnaire et un ajustement des connaissances en atelier de groupe. Chacun des 3 ateliers concerne un aspect du traitement : dietetique, vie sous pompe et securite. Resultats L’indication de la pompe a ete dans 60 % des cas une recherche d’un meilleur controle, dont 12 femmes en preparation de grossesse et dans 18 % des cas une instabilite glycemique. HbA1c avant pompe 7,9 % (5,7-11,6), sous pompe 7,1 % (5,2-13,5) sur l’ensemble du groupe ; 6,9 ± 0,6 chez les patients a 3 mois et 7,2 ± 1,2 chez les autres, anciennete de pompe 4,9 ± 5,6 ans. Ces patients font en moyenne 5,7 autocontroles glycemiques (mediane 6, 75 % ≥ 5). La securite a ete evaluee par un questionnaire comportant 8 points. Quatre-vingt neuf pour cent des patients recherchent l’acetone si la glycemie est > 2,5 g/ l, 60 % font alors un bolus au stylo, 37 % malheureusement a la pompe. 73 % ont un stylo de rapide en permanence sur eux. Par contre seuls 42 % savent interpreter un dosage de beta-hydroxybutyrate. Conclusion Nos patients sous pompe, initiee souvent apres plusieurs annees de diabete, ont un benefice qui se manifeste des les premiers mois et persiste au long cours. Ce benefice est a mettre en relation avec une autosurveillance intensive. Nos resultats montrent que les regles de securite sont majoritairement connues, et nous ne deplorons qu’une cetoacidose depuis 10 ans.

Management of very high insulin requirements in rare extreme insulin resistance syndromes is difficult and poorly documented. We report a case of a type B insulin-resistant patient requiring approximately 10,000 units of insulin per day, i.e. beyond the possibilities of current insulin formulations and delivery devices. Only the Panomat C10 portable pump model (Disetronic) and U500 Humulin (Lilly) allowed the required rate of 400 units per hour to be attained only when the reservoir was changed twice daily and the site and catheter were changed once daily. Three months after discharge, the patient was in good general and local condition, but with only fair diabetes control (glycated haemoglobin 9.5%).

Proximal diabetic neuropathy is a disabling neuropathy that occurs predominantly in non-insulin-dependent diabetic patients over the age of 50. Inflammatory lesions have been found in nerve biopsy specimens of diabetic patients with severe proximal neuropathy or with other patterns of multifocal neuropathy. Some of these patients respond dramatically to treatment with corticosteroids or with other immunomodulators. In this article we report on our findings in 4 additional patients with painful proximal diabetic neuropathy and different patterns of inflammatory nerve lesions whose condition improved spontaneously shortly after performance of a nerve biopsy, without additional treatment.

Objectif L’allergie a l’insuline (AI) est toujours observee avec l’insuline humaine et les analogues de l’insuline. Nous rapportons une serie de 42 patients consecutifs vus dans un centre unique pour suspicion d’AI avec hypersensibilite immediate. Nous presentons une procedure systematique de diagnostic et une strategie therapeutique. Patients et methodes 42 patients diabetiques de type 2 (n = 27) ou 1 (n = 15) adresses pour possible AI. Constitution selon des criteres cliniques precis, de 3 groupes : « AI evidente », « AI douteuse », « pas d’AI ». Les patients ont ete explores par prick-tests et tests intradermiques (IDR) a differentes insulines, dosage d’IgE anti-insuline et anti-protamine et un traitement a ete propose aux patients allergiques. Resultats Le groupe « AI evidente » comptait 19 patients âges de 52 ans (17–72), duree d’insulinotherapie 13 ans (0,5 a 41), HbA1c 8,7 % (6-14). Cinq etaient diabetiques de type 1 et 6 avaient une reaction generalisee. Seuls 3/15 pricks tests etaient positifs vs. 19/19 IDR. Les IgE anti insulines etaient positives chez 4/16, IgE antiprotamine toujours negatives (16/16). Trois patients ont stoppe l’insuline, 5 l’ont poursuivi avec ou sans antihistaminiques. Une perfusion continue sous-cutanee d’insuline (CSII), a ete utilisee chez dix autres patients. Trois des 9 patients classes « AI douteuse » avaient des IDR positives, et 5/5 des prick tests negatifs. Seul un patient du groupe juge « pas AI » (n = 14) avait un test IDR partiellement positif et 4/4 prick tests etaient negatifs. Conclusion Les tests intradermiques sont utiles pour confirmer ou infirmer le diagnostic de l’AI, les pricks tests semblent moins sensibles. La determination de leur sensibilite/ specificite necessite cependant une etude complementaire. Tous les cas peuvent etre controles par des mesures simples ou CSII.

Introduction La neuropathie diabetique (ND) est une complication frequente apres 20 ans de diabete mal controle. Elle entraine une perte de sensibilite thermo-algique. Lorsqu’elle atteint la mi-cuisse, il y a une perte de sensibilite des mains qui debute au bout des doigts. Ce travail illustre les lesions observees au niveau des mains chez 3 patients avec ND severe. Patients et methodes Photographie 1 : Patient âge de 80 ans, diabetique de type 2 mal controle depuis 32 ans avec retinopathie diabetique severe, presentant une ND qui a occasionnee des maux perforants chroniques et une amputation d’orteil. Il consulte en urgence pour une plaie etendue de la main : il s’est brule en posant la main sur une plaque de cuisson brulante dont il n’a pas percu la chaleur. Cas clinique Photographie 2 : Patient âge de 56 ans, diabetique depuis 16 ans, presentant un pied de Charcot et un mal perforant d’origine mixte : neuropathie alcoolique et diabetique. Il presente des lesions de brulure au troisieme degre des mains : il s’est brule avec son gobelet de cafe dont il n’a pas percu la chaleur. Photographie 3 : Patient âge de 49 ans diabetique de type 1 lent diagnostique il y a 3 ans avec retinopathie diabetique severe, ND et mal perforant. Il se blesse la main en bricolant et developpe rapidement un phlegmon extensif des tendons necessitant une chirurgie invasive, il garde des sequelles tendineuses invalidantes. Conclusion Ces observations temoignent du risque augmente de brulures et d’infections graves des mains chez les patients souffrant de ND etendue. Ces patients doivent beneficier de programmes educatifs cibles pour prevenir ces accidents.

A 21-year-old white woman (BMI 21.2 kg/m2) was admitted for management of uncontrolled diabetes with cutaneous allergies to insulin. Past medical history was marked by several allergies, including coconuts and penicillin with laryngeal edema. Type 1 diabetes was diagnosed 4 years previously and treated by three daily injections of semisynthetic human insulin (48 units/day). Four months later, the patient developed a local allergic reaction, a nettle rash without systemic manifestation that involved all injection sites. This reaction began

Introduction Quinze a 20 % des diabetiques de type 1 ont des anticorps anti-cellules parietales gastriques (PCA), ce qui expose a un risque theorique d’anemie, de maladie neurodegenerative et de tumeur gastrique. Cependant il n’y a pas recommandation quant au depistage de ces complications, en particulier en ce qui concerne l’indication de la fibroscopie gastrique. Materiels et methodes Etude de cohorte, depistage systematique des PCA. Analyse des parametres de la numeration sanguine, du bilan martial et donnees de la fibroscopie gastrique. Resultats 217 diabetiques de type 1 consecutifs, hospitalises. 37 (17 %) avec PCA. Les patients avec anticorps etaient plus âges (44 ± 13 vs 38 ± 12 ans, P = 0.006) et avaient plus frequemment des anti-TPO (54 % vs 26 %, P = 0.002). Dans cette cohorte la proportion de femme n’etait pas plus elevee parmi les patients avec PCA (65 % vs. 55 %, P = 0,4). Les patients avec PCA avaient une ferritinemie significativement plus basse (87 ± 104 vs. 119 ± 92 μg/l P = 10–4) ainsi qu’une concentration d’hemoglobine et un VGM plus bas (Hb : 13 ± 2 vs. 14 ± 1,3 g/dl, P = 510–5 ; VGM 85 ± 7 vs. 87 ± 4 μ3 ; P = 0,007). Significativement plus de patients avaient une anemie parmi les patients avec PCA (27 % vs 4 %, P = 310–5). Il n’y avait par contre pas de difference pour la vitamine B12, dosee cependant chez un nombre limite de patients (n = 33). On dispose des resultats de fibroscopie gastrique chez 10 patients avec PCA : 1 seule est normale, les autres montrent diverses anomalies, dont 2 tumeurs (1 carcinoide et 1 adenocarcinome in situ). Conclusion Nous confirmons la grande frequence de l’autoimmunite anti-estomac chez les patients diabetiques de type 1. La presence de PCA n’est pas anodine, elle s’associe a carence en fer et anemie. La carence en vitamine B12 pourrait etre plus tardive. Surtout, cette serie souligne la frequence des anomalies gastriques, et notre negligence a les depister… Une etude prospective multicentrique en precisera l’importance.

Introduction L’objectif etait de sensibiliser les patients DT2 a la reduction de la sedentarite et au developpement de l’activite physique au cours d’une hospitalisation programmee. Patients et methodes Il s’agit d’une etude de faisabilite. Les moyens developpes etaient : 1/ Formation de l’equipe soignante. 2/ Programme quotidien propose aux patients, autour du theme activite physique, impliquant chaque membre de l’equipe: infirmier, aide-soignant, dieteticien, medecin, kinesitherapeute. 3/ Presence d’un « expert » sport et selection de quelques patients pour le programme DiabetAction (programme canadien en cours d’implantation et d’evaluation en France. 4/ Seance de synthese de semaine reunissant l’equipe et l’expert sport. Resultats 42 DT2, âges de 60 ± 10 (m ± DS), 45% Femmes, diabetiques depuis 15 ± 9 ans, IMC: 33,5 ± 5,5 kg/m2 HbA1c 8,5% ± 1,8. Complications et facteurs de risque: retinopathie (32%), HTA (78%), hypercholesterolemie (73%), tabagisme(10%),apnee du sommeil (43%). Il s’agit d’une population inactive : score moyen d’activite (Ricci et Gagnon) 14 ± 7 et sedentaire (temps moyen de sedentarite : 6 h ± 4. Les patients ont tous participe avec enthousiasme a ce programme, et ont decouvert la possibilite de « bouger » avec plaisir. Huit patients volontaires ont ete selectionne pour suivre la « passerelle » PASS club = objectif initial. Les patients selectionnes ne differaient en aucun point des autres patients. Conclusion Cette etude de faisabilite a ete un succes et nous conduit a developper une etude prospective a long terme qui sera evaluee. La dynamique, la coherence et la cohesion de l’equipe soignante ont ete renforcees autour de ce theme que chacun s’est approprie.

Introduction Dans l’insulinotherapie fonctionnelle, reconnaitre les Glucides (G) et savoir en evaluer la quantite est un element primordial pour determiner la dose d’insuline prandiale. Lors d’un programme en ambulatoire, nous avons evalue en debut et en fin de session l’aptitude de nos patients a quantifier les G. Durant chaque seance, une part importante du temps est consacree a des exercices collectifs d’apprentissage de l’evaluation et de la quantification des G. Patients et methodes Soixante-sept patients (36H/31F), âges de 44,6 ans en moyenne et 21 ans de diabete en moyenne ont participe a l’etude. Ils sont tous traites par schema Basal Bolus. Le BMI etait de 24,6 en moyenne. L’HbA1c prelevee le 1 er jour du programme etait de 7,28 %. Nous disposons des resultats du dosage d’HbA1c 1 an apres la fin du programme pour 50 patients soit 75 %. La moyenne est de 7,2 %. Cinq plateaux repas exposant differentes quantites de G (20 a 130 g) ont ete presentes a la 1 re seance. Les patients devaient estimer rapidemment la quantite de G de chacun de ces plateaux. Les memes plateaux ont ete presentes lors de la 5 e seance. Sont consideres comme sachant compter les G les patients qui ont evalues a 20 g de G pres 3 plateaux sur 5. Resultats 56,7 % des patients ont su evaluer les quantites de G lors de la 1 re seance et 85 % a la derniere seance. L’evaluation des G etait ainsi significativement amelioree a l’issue du programme (p = 10 −4 ). En revanche, on constate que l’aptitude a compter les G n’est ni liee a l’anciennete du diabete, ni liee a l’HbA1c de depart. Pour les patients dont on dispose de l’HbA1c a 1 an, cette amelioration du comptage des G ne se traduit pas par une baisse de l’HbA1c. Conclusion Chez des patients insulinotraites ayant 21 ans de diabete, l’aptitude a evaluer les G reste mediocre et n’est pas correlee a l’HbA1c. Notre programme ameliore leurs connaissances dietetiques dans l’evaluation des quantites de G de leur alimentation. Toutefois, chez ces patients dont l’HbA1c est deja bonne a l’origine, cette amelioration de leurs connaissances dietetiques ne se traduit pas en baisse d’HbA1c a 1 an. Ces resultats doivent neanmoins etre consideres comme preliminaires et devront etre affines sur de plus grand effectifs.

Introduction Dans la prise en charge des patients diabetiques de type 2, les conseils hygieno-dietetiques representent une part importante du traitement. Dans le cadre d’un programme d’auto apprentissage en ambulatoire, nous leur apprenons a realiser leur auto enquete alimentaire (AEA) sur 3 jours. Munis d’une table de composition des aliments, ils devaient evaluer les quantites de Proteines, Lipides, Glucides et Alcool consommees, ainsi que l’apport calorique de la journee la plus representative. Ces AEA prealablement verifiees ont ete comparees a des enquetes alimentaires (EA) effectuees en debut de programme par une dieteticienne. Patients et methodes Vingt-neuf patients (14H/15F) âges de 58 ans en moyenne ont participe a l’etude. Vingt-cinq etaient traites par antidiabetiques oraux, 1 par insuline, 2 par traitement mixte et le dernier par regime seul. L’anciennete du diabete etait de 9 ans en moyenne. L’IMC moyen etait de 3, l’HbA1c en debut de programme de 6,8 % et de 6,7 % a l’issue des 4 seances (p = 0,053). Le metabolisme de base (MB) calcule selon la formule de Harris et Benedict nous donne en moyenne 1926 Calories (Cal). Resultats On observe une surestimation de l’apport calorique dans les EA due a des apports en Proteines (P) sous-estimes au detriment des Lipides (L) et des Glucides (G), mais ces resultats sont peu significatifs : Cal EA = 1892 vs Cal AEA = 1733 (p = 0,09) ; P EA = 79 g soit 17 % vs P AEA = 87 g soit 21 % (p g = 0,03 ; p % = 3,6 10 −6 ) ; L EA = 80 g soit 38 % vs L AEA = 68 g soit 35 % (p g = 0,03 ; p % = 0,09) ; G EA = 212 g soit 45 % vs G AEA = 191 g soit 44 % (p g = 0,08 ; p % = 0,13). 24 % de la population d’origine ayant consomme de l’alcool, aucune comparaison n’a pu etre effectuee. Conclusion Malgre une legere surestimation en calories des EA ceci ne remet pas en question leur fiabilite. Cela est d’autant plus probant qu’il y a une relative concordance entre le MB moyen et l’apport calorique de l’EA (p = 0,3). Toutefois, pour confirmer ces donnees, il aurait fallu confronter les resultats des MB par methode de calorimetrie a ceux obtenus par la formule utilisee chez ces memes patients.

The aim of the present study, a pilot trial, was to find out if nicotinamide (50 mg kg-1 day-1) in combination with cyclosporin A favours remission in recently diagnosed Type 1 diabetic patients, and if it postpones relapse even when cyclosporin A is administered in decreasing doses (trough blood level 300-500 micrograms l-1 until month 4, and 100-300 micrograms l-1 until month 9) and then discontinued. The criteria for inclusion in the study and the follow-up protocol were the same as those used in the Cyclosporin Diabetes France (CDF) programme in which all five of the centres involved in this study participated. The data of the present preliminary open study were therefore compared retrospectively with those of the placebo (CDF-placebo) and cyclosporin (CDF-active) group of the CDF programme. Clinical remission (fasting plasma glucose less than 7.8 mmol l-1, postprandial plasma glucose less than 11.1 mmol l-1, HbA1c less than 7.5% with neither insulin nor oral hypoglycaemic agents) was achieved within 6 months in 12 out of 35 patients (34%) vs 16 out of 63 (25%) in CDF-active and 11 out of 59 (19%) in CDF-placebo. Remission was achieved by month 9 in 6 out of 35 patients (17%) vs 13 out of 54 (24%) in CDF-active and 3 out of 52 (6%) in CDF-placebo. By 12 months remission persisted in 3 out of 35 patients (9%) vs 11 out of 63 (17%) in CDF-active and 0 out of 52 (0%) in CDF-placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

The hyperglycaemic effect of 20 g sucrose taken at the end of a regular mixed meal by diabetic patients was measured in six adult type 1 diabetics, C-peptide negative, controlled by the artificial pancreas, and twelve adult type 2 diabetics, with fasting plasma glucose levels below 7·2 mmol/l (130 mg/100 ml) and post-prandial plasma glucose levels below 10·0 mmol/l (180 mg/100 ml), treated by diet alone or with glibenclamide and/or metformin. All the patients were given on consecutive days, in random order, two mixed meals of grilled meat, green beans, and cheese, as well as a cake made either of rice, skimmed milk, and saccharine (meal A) or rice, skimmed milk, and 20 g sucrose (meal B). The meals contained equal amounts of calories and of carbohydrate. There was no difference between the meals in plasma glucose curves and plasma insulin or insulin infusion rate variations whether in peak values, peaking times, or areas under the curves, in either group of patients. Sparing use of sucrose taken during mixed meals might help well-controlled diabetic patients to comply with their daily dietary prescription while maintaining good blood glucose control.

We have evaluated the effects of metformin administration on erythrocyte insulin receptors in 21 subjects: 5 normal weight subjects, 5 obese non diabetics, 5 insulin-dependent diabetics (Type I) and 6 obese non insulin-dependent (Type II) diabetics. Plasma glucose, plasma insulin and erythrocyte insulin receptors were studied after 15 days of metformin (850 mg, t.d.) or placebo administered in a double blind random order. Maximum specific insulin binding to erythrocytes increased after metformin in the normals (p less than 0.01), in the obese non diabetics (p less than 0.01) and in the obese Type 2 diabetics (p less than 0.005), but not in Type I diabetics. Scatchard analysis showed that the receptor number per cell increased by 37% in the normals, by 17% in the obese non diabetics and by 182% in Type 2 diabetics. Receptor affinity increased in obese subjects but did not increase in normals and in diabetics. Only in Type II diabetics was there a significant decrease in plasma glucose. Metformin, thus, increased binding in normals by moderately increasing the capacity of cell receptors, in obese non diabetics by increasing the affinity, whereas in obese Type II diabetics it dramatically increases receptor capacity. This is consistent with the fact that metformin has a hypoglycaemic effect mainly in Type II diabetics, but not in non diabetics (whether obese or not), and could be due to a direct effect on the cell membrane.

Four months following hospitalisation. 160 insulin-treated patients were sent at their homes a questionary on home blood glucose monitoring. In hospital they had received no teaching specifically orientated towards this problem. From the usable replies (132) it was estimated that 11 +/- 8 (mean +/- SEM) sticks a week were used, most by diabetics in whom insulin therapy had been instituted less than a year before (p less than 0.01), more sticks were used by those who were thirty to forty years old, those who received three injections a day and those had distinct lesions of microangiopathy although the differences did not reach conventional levels of statistical significance. Neither sex nor the use of a finger- pricker system made a significant difference. The widespread use of home glucose monitoring shows the fortunate convergence of the physicians ' wishes (to obtain the best control of blood glucose level) and the patients needs (to obtain information, understanding, security and comfort).