[Pathologies of the musculoskeletal system in diabetes mellitus]. / Les complications musculo-squelettiques du diabète.

Diabetes mellitus causes several micro- (nephropathy, neuropathy and retinopathy) and macro-vascular (coronary insufficiency, stroke, lower limb arteriopathy) complications. Some complications are less widely known, particularly the ones involving the musculoskeletal system. Even though diabetes is not specifically linked to these complications, it increases both their incidence and severity. The objective of this paper is to review the main musculoskeletal complications associated to diabetes. It describes the pathophysiology, symptomatology and treatments of these complications.

Le diabète sucré entraîne toute une série de complications micro- (néphropathie, rétinopathie et neuropathie) et macro-vasculaires (coronopathie, accident vasculaire cérébral et artériopathie des membres inférieurs). Certaines complications sont moins connues, notamment celles qui touchent le système musculo-squelettique. Ces pathologies ne sont pas spécifiques du diabète, mais celui-ci en augmente fortement, non seulement, l'incidence, mais aussi la sévérité. Le but du présent article est de revoir les principales complications musculo-squelettiques que l'on peut rencontrer chez les personnes diabétiques, en décrire la physiopathologie, la symptomatologie et le traitement à préconiser.

[Diagnosis of lower limb pain in a diabetic patient]. / Vignette diagnostique de l'étudiant. Diagnostic différentiel des douleurs des membres inférieurs chez le patient diabétique.

By presenting this clinical case, we aim at discussing the diagnosis between arteriopathy, neuropathy and osteoarticular pathology in a patient with type 2 diabetes who complains of lower limb pain. We emphasize the role of a global medical approach based upon anamnesis and clinical exam, which should contribute to select the most helpful paraclinical investigations.

Cette vignette a pour but d'illustrer la démarche clinique permettant un diagnostic différentiel entre une artériopathie, une neuropathie et une atteinte ostéo-articulaire face à un patient diabétique de type 2 consultant pour des douleurs des membres inférieurs. La démarche médicale globale est privilégiée, se basant sur des éléments anamnestiques et cliniques qui doivent guider les investigations paracliniques.

Treatment by a moisturizer of xerosis and cracks of the feet in men and women with diabetes: a randomized, double-blind, placebo-controlled study.

AIM: To evaluate a moisturizer containing urea, glycerine and petrolatum for healing deep open fissures on the feet of people with diabetes. If left untreated, open fissures, an entry point for bacteria, can lead to infection, ulceration and further complications. METHODS: This randomized, double-blind, multicentre study at 19 hospitals, general practices and diabetologists in France and Belgium included participants with diabetes and a deep open target fissure on their heel. Participants were randomized to test cream or placebo (1 : 1) for 4 weeks. Complete target fissure healing after 4 weeks (primary criterion) and 2 weeks, target fissure closure, overall fissure healing and xerosis were assessed. RESULTS: Some 167 participants were randomized (80 to test cream; 87 to placebo); all were included in the efficacy analyses. The percentage of participants with complete target fissure healing after 4 weeks was higher with test cream than placebo (46.3% vs. 33.3%): the difference did not reach statistical significance (P = 0.088). Fewer participants still had a deep open target fissure with test cream than placebo, the difference was statistically significant and clinically relevant after 2 (24.7% vs. 42.7%, P = 0.027) and 4 weeks (6.4% vs. 24.1%, P = 0.002). The difference in overall fissure healing between test cream and placebo was significant (P < 0.001) and test cream resulted in greater xerosis improvement (P < 0.001 and P = 0.002 at 2 and 4 weeks, respectively). CONCLUSION: The activity of the test cream for treating feet fissures of people with diabetes was confirmed by an improvement in open fissure healing and xerosis. The cream was well tolerated.

[DIAGNOSTIC APPROACH OF THE PATHOPHYSIOLOGICAL TRIAD LEADING TO A DIABETIC FOOT]. / La vignette diagnostique de l'étudiant. Réflexion diagnostique à propos de la triade physiopathologique conduisant à la complication du "pied diabétique".

Diabetic foot is a common complication of diabetes mellitus. Its pathophysiology is most often complex with the interconnection of three different components: diabetic neuropathy, arterial disease and infection. The diagnostic approach should specify the respective role of each component, firstly thanks to a thorough medical interview and a careful clinical examination. Afterwards, well selected complementary exams will confirm the hypotheses generated by the initial clinical approach. Consequently, a specific care strategy will be implemented, ideally with the help of a multidisciplinary team. This educational clinical case is devoted to the sequential diagnostic approach of a patient with a foot ulcer in the context of a diabetic foot.

[Clinical evaluation of an obese person]. / La vignette diagnostique de l'etudiant. Mise au point d'un patient consultant pour obésité.

Obesity is increasingly prevalent in our society and medical consultations for evaluation and management of weight excess are frequent. Before considering a therapeutic strategy, a careful initial clinical assessment is mandatory. The diagnostic approach of an obese person should be similar as for any other chronic pathology. The objectives of the present clinical description are to report the main steps of an exhaustive anamnesis, the signs to be more specifically detected at the clinical examination and the other useful investigations to be programmed at first glance in a person who is visiting his/her medical doctor because of obesity. Based upon the data collected during this careful evaluation, therapeutic modalities may be defined, ideally in the frame of a multidisciplinary approach.

[European guidelines for the management of diabetes, prediabeties and cardiovascular disease. First part. Management of diabetes and cardiovascular risk factors]. / Srecommandations européennes pour la prise en charge du diabète, du pré-diabète et des maladies cardio-vasculaire. 1ère partie. Gestion du diabetè et des facteurs de risque cardio-vasculaire.

The patient with prediabetes or diabetes has a high or very high risk of cardiovascular diseases.We summarize the recent guidelines jointly published by the European Society of Cardiology and the European Society for the Study of Diabetes. In this first article, we focus mainly on the preventive approaches of cardiovascular diseases in patients with prediabetes or (type 1 or type 2) diabetes. The crucial importance of a global multifactorial strategy is emphasized and the target levels of various risk factors are updated. The management of these cardiovascular complications in presence of diabetes will be considered in a second article.

[Metabolic surgery: an increasing place in the management of diabetes]. / Chirurgie métabolique: une place croissante dans le traitement du diabète.

Bariatric surgery becomes more and more important in the management of the obese patient with type 2 diabetes, especially in case of failure of medical approaches. Metabolic improvement results not only from weight loss and the subsequent reduction in insulin resistance, but also from modifications of digestive hormones (especially incretins) that contribute to promote insulin secretion. This new paradigm, moving from bariatric surgery to metabolic surgery, opens new perspectives. The present article briefly describes innovative surgical techniques focusing on endocrine and metabolic improvement rather than on weight loss, the preliminary results of metabolic surgery in patients with type 2 diabetes and a body mass index <35 kg/m2 and, finally, some data regarding the surgical management of obese patients with type I diabetes not well treated with classical medical means.

[Obesity: a model of complex interactions between genetics and environment]. / L'obésité: un modèle d'interactions complexes entre génétique et environnement.

Obesity is explained by the joint actions of genetic susceptibility and environmental factors, such as a westernized lifestyle (sedentary lifestyle, calorie-dense foods), inducing an obesogenic environment. The search for obesity susceptibility genes remains complex, despite recent adavances made in the obesity genetics field. Except very rare monogenic type obesity, common obesity is thought to be polygenic and the genetic contribution to interindividual variation in common obesity has been estimated at 40-70 %. The genome-wide association studies have led to identify numerous genetic loci associated with body mass index and obesity risk. However, the predictive value of these loci to the obesity risk at the population level remains low. Finally, the influence of environmental factors on genetic susceptibility to weight gain is also related to epigenetic factors. Nutritional unbalance during fetal development may change the intrauterine environment and lead to altered gene expression (fetal programming) with alterations in DNA or histone methylation resulting in an increased susceptibility to chronic disease in adulthood, such as obesity.

[Obesity, insulin resistance and type 2 diabetes: risk factors for breast cancer]. / Obésité, insulinorésistance et diabète de type 2: facteurs de risque du cancer du sein.

Obesity and type 2 diabetes are two risk factors of breast cancer, especially after menopause. Underlying mechanisms are multiple and include hyperinsulinism due to insulin resistance (insulin, as insulin-like-growth factor -IGF-, is a growth factor), hyperleptinaemia associated with hypoadiponectinaemia, and high levels of estrogens resulting from aromatization of androgens in adipose tissue. In presence of type 2 diabetes associated with obesity, hyperglycaemia might provide energy substrate promoting tumour growth. These data have therapeutic implications with expected favourable effects of weight loss, resulting in a reduction of fat mass and insulin resistance, and the promising results recently reported with metformin contrasting with the negative effects of exogenous administration of high doses of insulin.

[Metabolic surgery: an evolution (or revolution) of bariatric surgery?]. / La chirurgie métabolique, vers une (r)evolution de la chirurgie bariatrique?

Bariatric surgery has proven its efficacy to obtain a marked and sustained weight loss and dramatically improves metabolic control in obese patients. The frequently observed remission of type 2 diabetes occurs very early, before any marked weight reduction. Increasing evidence suggests that this favourable effect results from profound changes in gut hormones involved in the regulation of energy intake behaviour and glucose homeostasis rather than simply from mechanical food restriction or malabsorption imposed by the surgical procedure. The better knowledge of these pathophysiological mechanisms, especially well studied with Roux-en Y gastric bypass, resulted in recent innovation in the technical procedures leading to a shift from bariatric surgery to metabolic surgery. Such type of surgery is currently evaluated in patients with type 2 diabetes, but with only a moderate obesity (BMI < 35 kg/m2), or even without obesity (BMI < 30 kg/m2). The Belgian Metabolic Intervention (BMI) Study Group would like to contribute very soon to this evaluation in a multidisciplinary approach.

[Management of an obese person with metabolic syndrome]. / La vignette thérapeutique de l'etudiant. Prise en charge d'une personne obèse avec syndrome métabolique.

The management of an obese person requires a careful evaluation first, a multidisciplinary approach and a stepwise therapeutic strategy. The latter should favour lifestyle modifications, eventually the use pharmacological agents in good responders, and reserve bariatric surgery to well selected cases, refractory to medical treatment. Continuous motivational reinforcement is crucial for long-term success. In obese individuals at high metabolic risk, such strategy should aim at reducing the incidence of new-onset type 2 diabetes.

[Recent advances in the management of obesity]. / Actualités thérapeutiques dans le domaine de l'obésite.

The management of an obese patient aims not only at obtaining a durable weight loss, but also at attenuating various associated risk factors. This latter objective may already be obtained with a rather moderate weight reduction (5-10% of initial body weight). The first step should favour life-style changes (diet and physical exercise), eventually together with a psychological support. In case of insufficient success, a pharmacological approach may be considered, in addition to life-style advices. Pharmacotherapy currently includes drugs that act on the central nervous system to decrease appetite (sibutramine), in the gastrointestinal tract to diminish fat absorption (orlistat) or at both central and peripheral sites (rimonabant). In case of extreme obesity or severe obesity associated with comorbidities, refractory to medical approaches, bariatric surgery may represent the only solution to obtain a major and sustained weight loss, together with a significant improvement of associated risk factors. Gastroplasty, especially laparoscopic gastric banding, has become very popular in our country. However, because of several limitations, it is increasingly replaced by derivative procedures, especially gastric bypass. In all cases, a multidisciplinary, integrated and individualized approach should be recommended, using realistic goals and targeting long-term weight reduction and improved health.

[Therapy of type 2 diabetes: between insulin sensitizers and insulin secreting agents]. / Le traitement du diabète de type 2: entre insulinosensibilisateurs et insulinosécrétagogues.

Type 2 diabetes is a complex disease characterized by a dual defect of insulin secretion and insulin sensitivity, which may vary from patient to patient, but also along the natural history of the disease in a particular patient. Besides the lifestyle changes, the treatment strategy comprises the administration of agents that promote insulin secretion and/or that improve insulin sensitivity. Drugs facilitating weight loss also improve glucose control by reducing insulin resistance. A global approach should be recommended to reduce the high cardiovascular risk of diabetic patients. The present article aims at summarizing our contribution to the development of drugs designed for the treatment of type 2 diabetes.

[Obesity and type 2 diabetes]. / Obésité et diabète de type 2.

Obesity is an epidemic disease associated with numerous cardiovascular risk factors as diabetes mellitus, dyslipidemia, hypertension. Insulin resistance seems to be an important promoter for the development of most of these abnormalities. Besides genetic background, obesity, especially abdominal adiposity, is by far the most important factor for the development of type 2 diabetes. The treatment of a diabetic obese subject begins with diet and regular physical activity, eventually with a psychological support. In case of failure of such lifestyle approach alone, addition of drug therapy should be considered. It may include pharmacological agents able to promote weight loss (orlistat, sibutramine, possibly rimonabant) and/or antihyperglycaemic compounds capable of reducing insulin resistance (metformin, glitazones, acarbose). In case of severe/morbid obesity complicated with type 2 diabetes not well controlled with medical means, bariatric surgery is the only treatment that can induce an important and sustained weight loss, associated with marked improvement of metabolic control and amelioration of overall prognosis.

[Bariatric surgery: 10-year results of the Swedish Obese Subjects Study]. / L'étude clinique du mois. Chirurgie bariatrique: les résultats à 10 ans de la "Swedish Obese Subjects Study".

The 10-year results of the prospective, controlled Swedish Obese Subjects Study were recently reported in the New England Journal of Medicine by L. Sjöström and colleagues. This trial compared obese subjects who underwent gastric surgery and contemporaneously matched, conventionally treated obese control subjects. The follow-up rate for laboratory examinations was 74.5 percent at 10 years. At that time, data of 627 patients of the control group (mean age of 48 years, body mass index of 41 kg/m2) were compared to those of 641 patients who were submitted to surgery (banding n = 156, vertical banded gastroplasty n = 451 and gastric bypass n =34). At 10 years, the body weight had increased by 1.6 percent in the control group and decreased by 16.1 percent in the surgery group (p < 0.001), and similar changes were observed for waist circumference (+2.8 percent versus -10.1 percent, respectively, p < 0.001). Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period. Ten-year rates of recovery from diabetes, hypertriglyceridaemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricaemia were more favourable in the surgery than in the control group. The surgery group had lower 10-year incidence rates of diabetes, hypertriglyceridaemia, and hyperuricaemia (but not of hypertension) than the control group. In conclusion, as compared with conventional therapy, bariatric surgery appears to be a valuable option for the treatment of severe obesity, resulting in long-term weight loss, improved lifestyle, and, except for hypercholesterolaemia that was not significantly affected, amelioration in cardiovascular risk factors that were elevated at baseline. Obtaining long-term data concerning the effect of weight loss on overall mortality and on the incidence rates of myocardial infarction, stroke, and cancer remains a key-objective of this landmark study.

Amputations in diabetic patients: a plea for footsparing surgery.

The authors observed a rather high rate of primary major amputation (above-knee or below-knee) performed for diabetic foot problems as well as an important revision rate for minor amputations (forefoot or toe) in diabetics. They reviewed their experience in order to compare it with more recent data from the literature, pleading for foot-sparing surgery. From 1993 to 1998, 186 amputations were performed on 146 diabetic patients. The cause of foot ulcers was neuropathy in 43 of them (51 episodes of diabetic foot problems) while in the remaining 103 patients (135 episodes of diabetic foot problems), diabetic macroangiopathy (absent ankle pulses) was on cause. For neuropathic foot problems, amputations were almost minor, resulting in a limb salvage rate of 90%. Only five of these patients (12%) had primary major limb amputation versus 43 of the dysvascular patients (42%). The reasons for major amputation by first intention were extensive tissue loss, intractable infection or non-reconstructible occlusive vessel disease, as judged by the surgeon. A foot-sparing surgery was attempted in 92 dysvascular cases. In only 44 of them, a preliminary vascular repair was performed. Twenty eight percent of the primary toe amputations and 24% of the forefoot amputations required secondary revision to a more proximal level. Minor amputations in case of diabetic neuropathy were characterized by a more favourable outcome: only 14% of the toe and 9% of the forefoot amputations failed. During follow-up, only 63% of the major amputations regained an autonomic walking capability with their prosthesis. Wound healing problems in diabetic foot are mainly due to infection and poor tissue perfusion. An aggressive control of the infection and distal revascularization of calf- or foot arteries, whenever possible, could improve the results of diabetic foot surgery. The poor functional recovery after major amputation (only 63% autonomic gait with limb prosthesis) argues for foot-sparing surgery whenever possible.

[Multidisciplinary management of the obese patient: example from the Obesity Center at the University of Liege]. / Un sujet obèse par une approche multidisciplinaire: l'exemple du Centre de l'Obésité du CHU Ourthe-Amblève.

Obesity is a mulfactorial disease whose prevalence is progressively increasing. Ideally, it requires a multidisciplinary management by medical doctors, dieticians, psychologists and kinetherapists. The new "Centre de l'Obésité" at the University of Liège aims at fulfilling such objectives with: 1) a first outpatient visit including the simultaneous participation of an endocrinologist, a dietician and a psychologist; 2) a structured and individualized programme of physical rehabilitation; 3) an individualized management of obese subjects as in-(hospital) and/or outpatients, using medical and/or surgical approaches; and 4) an opportunity to benefit of other specialized medical advices, if necessary, in order to increase both the efficacy and safety of the treatment. Owing to the increasing importance of obesity and the well-known difficulties to succeed in treating it, general practitioners should consider this new centre as a valuable help rather than a competitive structure for the management of their patients, especially those with severe or morbid obesity.

[Physical exercise for preventing obesity, promoting weight loss and maintaining weight management]. / L'exercice physique pour prévenir l'obésité, favoriser l'amaigrissement et maintenir la perte pondérale.

Obesity is a multifactorial disease making difficult the determination of the precise role of one specific factor such as physical activity or sedentary. Nevertheless, numerous arguments, derived from epidemiological observational studies or from randomized controlled interventional trials, support a favourable role of regular physical activity in the control of body weight. Physical activity contributes to prevent the occurrence of weight excess, especially in children or adolescents, to obtain a satisfactory weight loss, in general in combination with reduced-energy diets, and to maintain long-term weight loss. In addition, physical activity improves both the metabolic profile and health of obese subjects.

[Psychoactive substance abuse, behavioral disorder and depression during adolescence.]. / Consommation de substances psychoactives, troubles du comportement et sentiments dépressifs à l'adolescence.

This article examines coocurrence of three types of problems of adaptation during adolescence : abuse of psychotropic drugs, behavioral disorder (oppositional and behavioral disorders) and feelings of depression (depression and dysthymia). The study also examines behavioral, social as well as family characteristics which, during childhood, distinguish youths with many adaptation problems from those with only one or no problem. More than 1600 youths from all regions of Quebec participated in the study. These youths were around 15,7 years old when they completed an interview aiming at determining the possible presence of abusive use of psychotropic drugs, behavioral problems and feelings of depression. Their behavioral and sociofamilial characteristics had been previously evaluated (between the ages of 6 and 12) with questionnaires answered by parents and teachers. Results reveal that almost 10 % of youths experience two or three adaptation problems. These youths distinguish themselves from those with only one problem on various personal and sociofamilial dimensions in the course of childhood. Those with one problem represent a little more than 25 % of the sample. They also distinguish themselves from the group of youth with no problem on several variables. However, the group of youths with a problem of substance abuse only, is an exception. The discussion underlines the importance of knowing if there is simultaneous presence of several problems and proposes to intervene in a preventive fashion with youths who risk experiencing many problems.

[Clinical case of the month. MELAS syndrome]. / Le cas clinique du mois. Le syndrome MELAS.

A patient, born in 1961, was first examined for autoimmune hyperthyroïd at the age of 25. Then, several episodes of serious dehydration and alteration of general condition were followed by a severe encephalopathy with a symptomatology of stroke-like episodes, and during a hospitalization, a volvulus of the colon. Epilepsy developed also. A MELAS syndrome was diagnosed when she was 32 years old, based on her clinical metabolic history of the presence of Ragged-Red-Fibers at muscular biopsy and of the genetical analysis. At the age of 37, after a new episode of encephalopathy, the patient fell into a rapidly evolving coma and deces.