Influence of vitamin D supplementation on glycemic control in type 2 diabetics.

INTRODUCTION: Several studies have suggested a benefic impact of vitamin D supplementation on glycemic control and insulin resistance among patients with type 2 diabetes mellitus. The aims of our study were to assess vitamin D status in individuals with type 2 diabetes mellitus and to investigate the effects of vitamin D supplementation on glycemic measures in patients having vitamin D deficiency. METHODS: We conducted a comparative prospective study involved 100 Tunisian patients with type 2 diabetes followed at the National Institute of Nutrition and Food Technology of Tunis. Glycemic control and insulin resistance were evaluated in the beginning of the study and three months after supplementation. RESULTS: Baseline mean 25-Hydroxy vitamin D  (25(OH)D) level was 17.5±9.8 ng/ml. Vitamin D status was deficient in 60%, insufficient in 26% and sufficient in 14% patients. After vitamin D supplementation, mean serum 25(OH)D concentration increased significantly (p˂10-3). We observed a negative correlation between the variation of plasma 25(OH)D level and the waist circumference's variation (r=-0.266 and p=0.018). This correlation persisted after adjustment for therapeutic management. Vitamin D supplementation did significantly improve neither glycemic control nor insulin resistance parameters. CONCLUSION: Vitamin D deficiency is frequent in patients with type 2 diabetes mellitus. The metabolic effects of supplementation are controversial, hence the need of expanding studies to better demonstrate these effects.

[Correlations between insulin sensitivity with anthropometric and metabolic parameters in type 2 diabetics]. / Étude de la corrélation entre la sensibilité à l'insuline et les paramètres anthropométriques et métaboliques dans le diabète de type 2.

AIM: The aim of the study was to evaluate correlations between insulin sensitivity and insulinosecretion with anthropometric and metabolic parameters in type 2 diabetics. MATERIALS AND METHODS: We conducted a cross-sectional study among patients with type 2 diabetes mellitus treated with oral antidiabetic medications. The evaluation of insulin resistance and insulinosecretion was based on the calculation of the HOMA-IR and HOMA-ß indices. RESULTS: The mean age for the 100diabetes recruited was 56.4±8.4years. The mean body mass index (BMI) and waist circumference (WC) were 30.5±5.7kg/m2 and 101.2±11.9cm respectively. The HOMA-IR and HOMA ß indices were respectively 3.5±2.8 and 48.9±45.5. We have found a significantly positive correlation between HOMA-IR index and weight (r=0.406, p<10-3), BMI (r=0.432, p<10-3) and WC (r=0.412, p<10-3). We noticed a significant negative correlation between HOMA ß index and fasting glucose (r=-0.457, p<10-3) and A1C (r=-0.399, p<10-3). A positive statistically significant correlation was noted between HOMA-IR and HOMA-ß (r=0.400, p<10-3). CONCLUSION: Insulin resistance is very related to overweight, especially the android distribution of fat hence the need for adequate management of this android obesity. It would also be interesting to evaluate the effects of weight loss on insulin resistance parameters.

[Experimental determination of correction factors of four detectors used in small field radiotherapy]. / Détermination expérimentale des facteurs de correction de quatre détecteurs actifs utilisés pour la dosimétrie des minifaisceaux utilisés en radiothérapie.

PURPOSE: The aim of this work is to determine experimentally the correction factors [Formula: see text] for four active commercial dosimeters: two microchambers and two diode detectors based on the output factor measured with radiochromic film for a radiotherapy linear accelerator equipped with circular cones. MATERIALS AND METHODS: Initially, a radiochromic film dosimetry measurement protocol with an accuracy of 2% was developed to approach the "reference output factor". Afterwards, the corrective factors of four detectors were determined for two ionization chambers (PinPoint PTW 31016 3D, Micropoint Extradin A16) and two diodes (PTW T60017 Diode, PTW-60019 Micro-Diamond). These measurements were carried out under conical BrainLAB® collimators defining circular fields with diameters equal to 7.5mm, 10mm, 12.5mm, 15mm, 17.5mm, 20mm, 25mm, 30mm, 35mm and 45mm of a 6MV X-ray beam generated by the ClinaciX linear accelerator (Varian®). These factors are weakly dependent on the type of accelerator, whether the model and the collimation type. This allowed their comparisons with those published for the same type of detector and for an accelerator with the same index of beam quality. RESULTS: The correction factors obtained experimentally were comparable in maximum deviation of 1.9% with published ones of the works using the same type of detector (mark and model) and an accelerator delivering the same beam quality for the same field size at the measurement point. CONCLUSION: The measurement protocol using the EBT3 film, which was used as a passive dosimeter to determine the "reference output factor", was validated by comparing measured and published data of active detector correction factors.

A Case of Resistance to Thyroid Hormone with Chronic Thyroiditis: Discovery of a Novel Mutation (I54V).

Resistance to thyroid hormone (RTH) is a rare disorder characterized by variable tissue hyporesponsiveness to thyroid hormone, usually caused by mutations in the thyroid hormone receptor beta (TRß). It has been reported that the serum of patients with RTH is free of auto-antibodies against thyroglobulin (Tg) and thyroid peroxidase (TPO), except in rare cases where coincidental autoimmune thyroiditis is also present. We describe a 13-year-old girl with chronic thyroiditis and RTH. This patient had increased plasma free T3, free T4 at the upper limits with unsuppressed TSH. She had peripheral manifestations of thyroid hormone excess, hypertension and growth acceleration. Anti-TPO antibodies were positive. Sequence analysis of the TRß gene was performed and revealed a novel mutation I54V in exon 4. The same mutation was also found in the mother and two asymptomatic sisters. The clinical presentation of our patient is not habitual in RTH because growth retardation is frequently reported in this syndrome. The association between RTH and thyroiditis complicate the management of the hypothyroidism.

[Growth hormone deficiency and pituitary stalk interruption in Fanconi anemia]. / Déficit en GH par interruption de la tige pituitaire dans l'anémie de Fanconi.

Fanconi anemia is a rare disorder inherited by recessive autosomic transmission belonging to the group of chromosomal instability syndromes. It is characterized by progressively developing medullary aplasia, various congenital malformations and especially a high risk of cancer, particularly acute myeloblastic leukemia and certain solid tumors. The association is quite common in patients with endocrine disease which constitutes an additional factor of morbidity and must be diagnosed and treated. We report a case of Fanconi anemia revealed by severe delay in statural growth and primary amenorrhea with a 21-year-old girl. The diagnosis was suggested by asymptomatic pancytopenia caused by a medullary hypoplasia and confirmed by a cytogenetic investigation using cross-linking agents that showed a large number of chromosomal breaks. Hormonal exploration revealed hypopituitarism with complete growth hormone (GH) deficiency and hypogonadotrophic hypogonadism caused by interruption of the pituitary stalk. The aim of this case report is to illustrate the importance of early exploration of retarded growth which, in some patients, can reveal potentially serious, and treatable, disease.

Prevalence of metabolic abnormalities in the Tunisian adults: a population based study.

AIMS: To estimate the prevalence of individual metabolic abnormalities and the cluster of metabolic abnormalities in a representative sample of the Tunisian adult population and to identify their relationship with gender, age and residency. The definition used is an adaptation of the NCEP ATP III definition, using total cholesterol>or=5.2 mmol/l instead of HDL-cholesterol. MATERIALS AND METHODS: We used a sample of the Tunisian National Nutrition Survey (TNNS), a cross-sectional health survey conducted in 1996, to estimate the nutritional status of the population. The TNNS included 2 927 adults aged 20 years or older who had measurements of height, body weight, waist circumference, blood pressure, fasting plasma glucose, total cholesterol and triglycerides. The cluster of metabolic abnormalities was defined as the presence of three or more metabolic abnormalities. RESULTS: The prevalence of abdominal obesity, hypertriglyceridemia, high total cholesterol, high blood pressure and high fasting plasma glucose was, respectively, 9%, 23%, 24%, 45% and 15% in men and 33%, 19%, 29%, 44% and 15% in women. The prevalence of the cluster was more frequent in women than in men (18% versus 13%, P<0.001) and in those living in urban communities (21% in women, 16% in men) rather than rural communities (11% in women, 8% in men) (P<0.001). The prevalence also increased significantly with age (P<0.001). CONCLUSION: The cluster of metabolic abnormalities and its components are common in the Tunisian adult population and prevalence increases significantly with female sex, urban residency and age.

[Ramadan fasting in type 2 diabetes mellitus]. / La pratique du jeûne du mois de Ramadan chez le diabétique de type 2.

This study was designed to assess the effects of fasting during Ramadan on weight, blood pressure, metabolic control and plasma lipoproteins in diabetic patients. This study was conducted in December 2000 (Ramadan 1421) when the length of fasting was 12 hours a day. It included 38 type 2 diabetic patients (20 males and 18 females). Mean patient age was 51.410.5 years and mean body mass index (BMI) 28.94.7kg/m2. Three patients were treated with diet and 35 with oral hypoglycemic agents. Clinical and biochemical parameters were evaluated during three periods: three weeks before Ramadan (T0), at the fourth week of Ramadan (T1) and three weeks after the end of Ramadan (T2). During the month of Ramadan, a decrease in weight (0.52kg) and no change in blood pressure were observed. No metabolic complication occurred in our patients. A significant effect of Ramadan fasting was observed on glycemic control and lipoprotein levels. In patients whose fructosamine level before Ramadan was higher than 340micromol/l, plasma fasting glucose and serum fructosamine increased during Ramadan (p<0.003) and returned to initial levels at the end of Ramadan T2; in these patients also, a decrease of HDL-cholesterol (p<0.01) associated with an increase of LDL-cholesterol (p<0.003) were observed at T1 and disappeared at T2. But, in patients whose fructosamine level at T0 was lower than 340micromol/l, no effect on glycemic control and no significant effect on serum lipoprotein levels were found during Ramadan month. Ramadan fasting in type 2 diabetic patients seems to cause slight effects on glycemia and lipoprotein levels when previous metabolic control is quite good; but fasting induces more deterioration when previous control is poor.

Celiac disease in adult patients with type 1 diabetes mellitus in Tunisia.

OBJECTIVE: Type1 diabetes mellitus may be associated with celiac disease. The prevalence of celiac disease as determined by screening among adult patients with type 1 diabetes is high with rates of 1.07.8% in Europe and U.S.A. The aims of the study are to determine the prevalence of celiac disease in adults with type 1 diabetes in Tunisia. METHODS: 348 consecutive adult patients with type1 diabetes were investigated prospectively and screened for celiac disease. The mean age was 28.45+/-10.74 years old. There were 176 females and 172 males. For the screening of celiac disease, we used immunoglobulin A (IgA) anti-endomysium (EMA) antibodies determined by an indirect immunofluorescence method. Anti-transglutaminase (tTG) antibodies were determined by an ELISA method. Those patients with positive results for anti EMA and or tTG were proposed for duodenal biopsy. RESULTS: 14 patients were positive for anti EMA and had high or a weak positive level of tTG antibodies. One patient from this group was already known to have celiac disease. Only 8 patients consented to biopsy and morphological changes were consistent with celiac disease in all cases. Prevalence of biopsy-proven celiac disease was 2.3% (95% CI=1.0-4.5%). CONCLUSION: The present study confirms that celiac disease of adults is prevalent in type 1 diabetic patients in Tunisia. Serological screening for celiac disease in type 1 diabetes is important because many patients are asymptomatic and most are detected by the screening.

[Prevalence and clinical aspects of superficial mycosis in hospitalized diabetic patients in Tunisia]. / Prevalence et aspects cliniques des mycoses superficielles chez le diabétique tunisien en milieu hospitalier.

OBJECTIVES: The prevalence of mycotic infection seems to be higher among diabetic patients than in the non-diabetic population. The aims of this study were to determine the frequency of mycosis and to compare clinical and fungal results. PATIENTS AND METHODS: This transversal study included 307 type 1 and 2 diabetic patients admitted between January 1998 and January 2000. A dermatologist examined all patients. The mean age was 44 +/- 17 years and the duration of diabetes 8 +/- 6 years. Patients with suspected lesions underwent mycological examination. RESULTS: Clinical signs of presumed fungal infection were found in 61% of patients, but mycosis was confirmed only in 30%. Fungal foot infection accounted 38% of the patients, mostly due to dermatophytes (94%). The commonest localizations of dermatophytes were interdigital (60%) followed by onychomycosis (30%). The main fungal agent was Trichophyton rubrum. The main risk factors for fungal infections were the age of patients (P = 0.0003) and duration of diabetes (P < 0.05). Interdigital foot localization of dermatophytes was correlated to age (P < 0.0001) and to the male gender (P < 0.01). The frequency of dermatophytes in nails was higher in type 2 diabetic patients (P < 0.01). Vulvovaginal candidosis and interdigital dermatophytes were more frequent in obese than in non-obese patients. The accuracy and specificity of direct examination were respectively 85% and 79%. CONCLUSION: The high frequency of mycosis in diabetic patients at hospital is demonstrated. The main risk factors were age, male gender and obesity.

[Obstructive acute renal failure revealing visceral leishmaniasis in a diabetic patient]. / Une insuffisance rénale aiguë obstructive révélant une leishmaniose viscérale chez un diabétique.

We report a case of a 22 years old type 1 diabetic man with a history of weight loss, weakness, anorexia, fever and recurrent urinary tract infection since February 2001. In April 2001, he presented anuria due to obstructive acute renal failure. Hepatosplenomegaly and lymphadenopathy were absent at physical examination. Laboratory tests revealed a high level of gamma globulin (53.4 g/l) and anaemia (haemoglobin 7.7 g/100 ml) without leukopenia and thrombocytopenia. CT scan showed multiple retroperitoneal lymphadenopathies causing compression of the two ureters, hydro-ureter associated with hydronephrosis, hepatosplenomegaly and multiple pulmonary nodes. Lymphadenopathies, anaemia, high level of gamma globulin, high titres of anti-leishmanial antibodies and the excellent outcome after treatment with meglumine antimoniate (Glucantime) confirmed visceral leishmaniasis. This report documented an unusual clinical presentation of Visceral leishmaniasis in a diabetic patient.

[Cortisol rhythm during the month of Ramadan]. / Rythme du cortisol pendant le mois de Ramadan.

We studied the nyctohemeral cortisol secretion rhythm and the cortisol response to 1-24 corticotropin during Ramadan in 11 healthy, male volunteers aged 20-35 years. Their response to 250 mg 1-24 corticotropin was investigated 2 weeks before Ramadan by testing daily at 08:00 and 20:00 hours. After 16-22 days of fasting, their cortisol levels were measured at 08:00 hours and their response to 1-24 corticotropin at 20:00 hours. Before Ramadan, the baseline cortisol level was significantly higher at 08:00 hours than at 20:00 hours and the cortisol response to 1-24 corticotropin was also higher at 08:00 hours but this difference was not significant. During Ramadan, the cortisol level at 08:00 hours was lower than at the same time before Ramadan; the level at 20:00 hours was slightly higher than at the same time before Ramadan. There was no significant difference between the cortisol response to 1-24 corticotropin at 20:00 hours during Ramadan and the responses before Ramadan at 20:00 hours and 08:00 hours.

[Diabetic fibrous mastopathy: a case report]. / Mastopathie fibreuse diabétique.

Diabetic fibrous mastoplasty or diabetic fibrous breast disease is a benign condition rarely observed. First described in 1984, it can lead to misdiagnosis because it simulates breast cancer. Diabetic fibrous mastoplasty usually occurs in patients with autoimmune disorders, particularly in patients with longstanding and complicated insulin-dependent diabetes mellitus. We present a case of fibrous mastoplasty in a patient with insulin-dependent diabetes mellitus known for 17 years. The clinical and radiological features and the clinical course are illustrative. We discuss the different pathogenic theories put forward.

[Circadian rhythm of cortisol and its responsiveness to ACTH during Ramadan]. / Variations de la cortisolémie et de sa réponse à l'ACTH pendant le mois de Ramadan.

UNLABELLED: Changes in the nyctemeral pattern observed during Ramadan include diurnal fasting from sunrise to sunset and delayed and shortened periods of sleep. The purpose of the present study was to investigate the possible effect of these changes on the circadian rhythm of cortisol and its response to exogenous ACTH. SUBJECTS AND METHODS: Eleven healthy male volunteers aged 20 to 35 years were studied for two weeks prior to Ramadan. Two short ACTH stimulation tests (250 microg ACTH 1-24 intravenously) at 8 a.m. and 8 p.m. An average 17 days after the beginning of the month of Ramadan, basal cortisol was measured at 8 a.m. and a short stimulation test was performed at 8 p.m. RESULTS: Before Ramadan, cortisol level was higher at 8 a.m. (749.5 +/- 207 nmol/l) than at 8 p.m. (195.18 +/- 79 nmol/l, p<0.001) and the incremental cortisol response to exo genous ACTH was higher at 8 a.m. (peak at 1.167 +/- 46 nmol/l) than at 8 p.m. (peak at 950 nmol/l) (NS). During Ramadan, morning cortisol level (646.3 81 nmol/l) was lower than before Ramadan (NS). The 8 p.m. cortisol level (319 193 nmol/l) increased slightly during Ramadan (p=0.08) but remained lower than the morning level during Ramadan (p=0.001) and before Ramadan (p<0.001). There was not significant difference between cortisol responsiveness to exogenous ACTH at 8 p.m. during Ramadan (peak at 1.102 51 nmol) and at 8 a.m. and 8 p.m. during Ramadan. DISCUSSION: Changes in eating and sleeping schedule was found to reduce morning cortisol level and raise the evening cortisol level. Adrenal sensitiveness to corticotropin stimulation did not appear to be impaired during Ramadan.