[Nasal glucagon (Baqsimi®), new treatment for hypoglycaemic coma]. / Le médicament du mois. Le glucagon nasal (Baqsimi®), nouveau traitement du coma hypoglycémique.

Patients with insulin-treated type 1 diabetes (T1D) are exposed to hypoglycaemia, which may be serious. Serious cognitive impairment (including coma and seizure) that requires the help of a third party is a medical emergency. Besides the intravenous injection of glucose by a health care provider, its treatment consists of the subcutaneous or intramuscular injection of glucagon which may be performed by a family member. However, such an injection is not easy and puts off some people, which retards the initiation of a potentially life-saving therapy. The intranasal administration of 3 mg glucagon has been shown as efficacious as the subcutaneous or intramuscular injection of 1 mg glucagon in controlled studies carried out in both adult and youth patients with T1D. Stimulation and real-life studies among caregivers, patients and acquaintances showed a preference for nasal glucagon because of its easy and quick use. The launch of nasal glucagon (Baqsimi®) offers new perspectives for the ambulatory emergency management of severe hypoglycaemia and hypoglycaemic coma with a special obvious advantage in children.

La personne avec un diabète de type 1 (DT1) traité par insuline est exposée à un risque d'hypoglycémie, parfois grave. L'hypoglycémie sévère qui désigne tout trouble cognitif grave (y compris coma, convulsion) nécessitant l'intervention d'un tiers est une urgence médicale. Outre l'injection de glucose par voie intraveineuse, réservée à un personnel de santé, le traitement consiste en l'injection de glucagon par voie sous-cutanée ou intramusculaire qui peut être réalisée par un membre de l'entourage. Cependant, cette injection n'est pas aisée et rebute certaines personnes, ce qui retarde la mise en route d'un traitement potentiellement salvateur. L'administration nasale de glucagon 3 mg s'est avérée aussi performante que l'injection sous-cutanée ou intramusculaire de 1 mg dans des études contrôlées réalisées chez des patients DT1 adultes ou enfants/adolescents. Des études de simulation et de vraie vie réalisées auprès de soignants, de patients et de connaissances ont montré une préférence pour la forme nasale en raison de sa facilité et rapidité d'utilisation. La commercialisation du glucagon nasal (Baqsimi®) offre de nouvelles perspectives pour le traitement d'urgence ambulatoire de l'hypoglycémie sévère et du coma, avec un avantage particulièrement évident chez les enfants.

[Gestational diabetes mellitus : prelude of risks not to be misunderstood]. / Le diabète gestationnel. Prélude de risques à ne pas méconnaître.

Gestational diabetes mellitus is a common complication in pregnant women. It is diagnosed between the 24th and 28th last menstrual period thanks to an oral glucose tolerance test with 75 g of glucose. Although blood glucose levels usually return to normal after childbirth, it can lead to some medium- and long-term complications, including cardiovascular, metabolic and renal complications. Early detection of various risk factors related to these complications would avoid some negative consequences for women with background of gestational diabetes.

Le diabète gestationnel est une complication fréquente chez la femme enceinte. Il est diagnostiqué entre la 24ème et la 28ème semaine d'aménorrhée grâce à la réalisation d'une hyperglycémie provoquée par voie orale avec 75 g de glucose. Même si la glycémie se normalise après l'accouchement dans la plupart des cas, un antécédent de diabète gestationnel peut entraîner différentes complications à moyen et long termes, notamment sur le plan cardiovasculaire, métabolique et rénal. Un dépistage précoce des différents facteurs de risque liés à ces complications permettrait d'éviter certaines conséquences néfastes pour les femmes après un diabète gestationnel.

[Crossed eyes on arterial blood pressure in sitting position]. / L'image du mois. Regards croisés sur la pression artérielle en position assise.

Prolonged standing or even sitting position can induce a fall in arterial blood pressure because of gravity that provokes a blood volume sequestration in lower limbs. Such a phenomenon may be associated with orthostatic dizziness or sometimes syncope. We present the image of a continuous monitoring using a Finometer® of systolic blood pressure and heart rate. Crossing legs while in sitting position allows immediate increase of arterial blood pressure. This pathophysiological mechanism explains why numerous people cross legs in sitting position, for instance during a prolonged meeting, in an auditorium or in a movie theater. This common phenomenon has potential diagnostic, therapeutic and prognostic implications.

La position debout, ou même assise, prolongée peut entraîner une baisse de la pression artérielle compte tenu d'une certaine séquestration du volume sanguin dans les membres inférieurs due à la gravité, ce qui peut provoquer un malaise lipothymique, voire une syncope. Nous présentons l'image d'un enregistrement continu, avec un Finometer®, de la pression artérielle systolique et de la fréquence cardiaque, démontrant que le simple fait de croiser les jambes en position assise permet de faire remonter, quasi instantanément, la pression artérielle. Ce mécanisme physiopathologique explique pourquoi de nombreuses personnes croisent les jambes en position assise, que ce soit, par exemple, lors d'une réunion prolongée, dans un auditoire ou dans une salle de cinéma. Ce phénomène, a priori banal, a potentiellement des implications diagnostiques, thérapeutiques et pronostiques. Mots-clés : Pression artérielle - Hypotension - Position corporelle - Mesure continue - Finometer®.

[Ultra-rapid lispro (Lyumjev®)]. / Le médicament du mois. L'insuline ultra-rapide lispro (Lyumjev®).

Development of new insulins aims to mimic in a better way the natural physiology of this hormone secreted by the pancreas. Rapid insulin analogues have proven a better capacity to reduce postprandial glycaemic peaks after eating. Nevertheless, these molecules are still quite inaccurate to limit glycaemic excursions after the meals. This reality is often described by patients using continuous glucose monitoring systems. So, there is undeniably a place for even more rapid insulins. The ones named «ultra-rapid insulin¼ tend to better control hyperglycaemia after meals thanks to more favourable profiles regarding pharmacodynamics and pharmacokinetics. Ultra-rapid lispro (URLi) Lyumjev®, is the new ultra-rapid insulin available in Belgium. This review aims to describe its advantages compared to some other rapid insulins thanks to data obtained from trials in type 1 and type 2 diabetes.

: L'arrivée des nouvelles insulines est motivée par la volonté de proposer aux personnes diabétiques un traitement avec des molécules qui s'approchent le plus de la physiologie normale de cette hormone. Le développement des analogues rapides de l'insuline avait comme objectif de mieux mimer la sécrétion endogène d'insuline après chaque prise alimentaire. Ces molécules ont démontré des avantages par rapport aux insulines humaines précédentes grâce à une plus grande rapidité d'action après l'injection sous-cutanée. Néanmoins, ces analogues rapides restent imparfaits en termes de rapidité d'action et de pharmacocinétique au sens large. Les personnes diabétiques de type 1 observent régulièrement des phénomènes d'hyperglycémies postprandiales lorsqu'elles utilisent les mesures continues ou intermittentes du glucose interstitiel. Dès lors, de nouvelles insulines, dites «insulines ultra-rapides¼, ont comme objectif d'améliorer encore cette cinétique de l'insuline injectée avant un repas, en agissant «vite et fort¼ pour maîtriser, au mieux, le pic glycémique postprandial. L'insuline ultra-rapide lispro (URLi), Lyumjev®, est la nouvelle insuline de ce type commercialisée en Belgique. Le but de cette revue est de décrire ses avantages par rapport à d'autres insulines rapides grâce aux données actuellement disponibles, à la fois dans le diabète de type 1 et de type 2.

[Therapeutic and technological advances in the management of adult patients with type 1 diabetes]. / Avancées thérapeutiques et technologiques dans la prise en charge du patient diabétique de type 1 adulte.

Management of type 1 diabetes remains a challenge. Indeed, many parameters can influence glycemia. Faced with this challenge, recent years have seen the emergence of various advances. These ones relate not only to new therapeutics but also to techniques dedicated to the management of type 1 diabetes. Among the therapeutic advances, the main ones concern improvement of pharmacokinetic and pharmacodynamic properties of insulins. Some other drugs might be worth considering, such as gliflozins in particular. In addition to these advances, the technological aspect of care continues to improve. There are many new possibilities with continuous insulin infusion pumps. The (semi-) continuous glucose monitoring clearly revolutionized the approach. Coupling this continuous measurement with some insulin pumps allows some patients to benefit from hybrid artificial pancreas. This article briefly discusses advances of the past decade in the management of adults with type 1 diabetes.

La prise en charge du diabète de type 1 reste un challenge. En effet, de nombreux paramètres peuvent influencer la glycémie. Face à ce défi, ces dernières années ont vu l'émergence de différentes avancées. Celles-ci concernent à la fois les thérapeutiques mais également les techniques dédiées à la prise en charge du diabète de type 1. Parmi les avancées thérapeutiques, les principales concernent l'amélioration des propriétés pharmacocinétiques et pharmacodynamiques des insulines. En outre, certaines autres classes de médicaments méritent d'être envisagées, comme les gliflozines notamment. A côté de ces progrès, l'aspect technologique de la prise en charge ne cesse de s'améliorer. Les pompes à perfusion continue d'insuline offrent de nombreuses nouvelles possibilités. La mesure (semi)-continue du glucose a clairement révolutionné l'approche envisagée. Le couplage de cette mesure continue du glucose à certains types de pompes à insuline permet d'offrir à des patients sélectionnés de bénéficier de pancréas artificiel hybride. Cet article aborde les avancées de cette dernière décennie dans la prise en charge des personnes adultes diabétiques de type 1.

[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.

[An unusual cause of kidney disease in a diabetic patient]. / Le cas clinique du mois. Piège diagnostique d'une protéinurie chez un patient diabétique.

Diabetic nephropathy is a complication of diabetes that affects 25-40 % of diabetic patients. This complication is usually associated with other microangiopathic disorders. We describe a case of a patient suffering from type 2 diabetes with proteinuria, and no signs of retinopathy. This case allows us to discuss and review different etiologies of proteinuria in diabetic patients, particularly in patients who don't suffer from retinopathy.

La néphropathie diabétique est une complication qui affecte 25 à 40 % des patients diabétiques. Cette complication est classiquement associée à d'autres atteintes microangiopathiques. Nous rapportons ici l'histoire d'un patient diabétique de type 2 présentant une protéinurie sans signes de rétinopathie. Ce cas permet de discuter des différentes étiologies d'une protéinurie chez les patients diabétiques, en particulier chez les patients sans rétinopathie.

[Role of metformin in gynaecology and obstetrics]. / Comment je traite Place de la metformine en gynécologie-obstétrique.

Metformin raises much interest in the fields of gynaecology and obstetrics. This article discusses both the efficacy and safety of metformin in the management of polycystic ovary syndrome as well as in the prevention, treatment and follow-up of gestational diabetes. Recent observational data suggest that metformin may also exert positive effects as adjuvant therapy in some cancers, among which endometrial cancer and breast cancer.

La metformine suscite un réel intérêt dans le domaine de la gynécologie et de l'obstétrique. Cet article discute l'efficacité et la sécurité de la metformine dans la prise en charge des femmes avec un syndrome des ovaires micropolykystiques ainsi que dans la prévention, le traitement et le suivi d'un diabète gestationnel. Des données observationnelles récentes suggèrent également que la metformine pourrait jouer un rôle favorable comme traitement adjuvant dans certains cancers, dont ceux de l'endomètre et du sein.

[Contribution of FreeStyle Libre® in the care of diabetic patients : experience at the CHU of Liege]. / L'apport du système FreeStyle Libre® dans la prise en charge du patient diabétique : expérience au CHU de Liège.

Since July 2016, diabetic patients included in the INAMI glycemic self-monitoring system in category A in Belgium can benefit from a new system for measuring the concentration of subcutaneous glucose : FreeStyle Libre® (FSL) from Abbott company. The main advantage of this technology is that it is less invasive as it does not require finger blood sampling and allows patients to obtain, in addition to the instantaneous value of glucose concentration, retrospective kinetic data, but also prospective trend of its kinetics. In this study, we mainly evaluated the contribution of FSL on the overall equilibration of diabetes and on the time spent in hypoglycaemia. We also asked patients how satisfied they were with this system. Data from 838 diabetic patients (type 1 or total insulin deficiency) were collected between May 2016 and October 2017, 645 patients with FSL system and 193 preferring to continue self-monitoring of capillary blood glucose (SBG). In the FSL group, compared to the SBG group, there was a slight decrease in HbA1c estimated at 0.15 ± 0.073 % after 15 months. This decrease appears mainly when the starting level is high (HbA1c superior to 7.5 %). Patients perform an average of 8.8 checks per day : the more patients perform daily scans, the greater the number of data comprised within the target, that is, the better the overall glucose control. A higher number of scans is also associated with a decrease in the average duration of hypoglycaemia. Finally, the satisfaction survey shows a high degree of patient satisfaction with the use of FSL.

Depuis juillet 2016, les patients diabétiques inclus dans la convention d'auto-surveillance glycémique de l'INAMI en catégorie A en Belgique peuvent bénéficier d'un nouveau système de mesure de la concentration du glucose sous-cutané : le FreeStyle Libre® (FSL) de la société Abbott. L'avantage principal de cette technologie est qu'elle est moins invasive puisqu'elle ne nécessite pas de prélèvement sanguin et qu'elle permet aux patients d'obtenir, outre la valeur instantanée de la concentration de glucose, des données cinétiques rétrospectives, mais aussi une tendance prospective de son évolution. Dans cette étude rétrospective, nous avons évalué principalement l'apport du FSL sur l'équilibration du diabète et sur le temps passé en hypoglycémie. Nous avons également interrogé les patients sur leur degré de satisfaction vis-à-vis de ce système. Les données de 838 patients diabétiques (type 1 ou totalement insulinoprives) ont été collectées entre mai 2016 et octobre 2017, 645 patients porteurs du système FSL et 193 préférant poursuivre une auto-surveillance de la glycémie capillaire (ASG). On observe dans le groupe FSL, par rapport au groupe ASG, une légère diminution du taux d'HbA1c évaluée à 0,15 ± 0,073 % après 15 mois. Cette diminution apparaît principalement lorsque le niveau de départ est élevé (HbA1c sup�rieur a 7,5 %). Les patients porteurs du FSL réalisent en moyenne 8,8 contrôles quotidiens : plus les patients effectuent de scans journaliers, plus le nombre de données comprises dans la cible augmente, c'est-à-dire meilleur est l'équilibre glycémique. Un nombre plus élevé de scans est également associé à une diminution de la durée moyenne des hypoglycémies. Enfin, l'enquête de satisfaction démontre, dans l'ensemble, un haut degré de satisfaction des patients par rapport à l'usage du FSL.

[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.

[Contribution of continuous glucose measurement in the management of gestational diabetes : a pilot study]. / Intérêt de la mesure continue du glucose dans la gestion du diabète gestationnel : une étude pilote liégeoise.

The prevalence of gestational diabetes increases as a result of universal screening, but also because of more stringent diagnostic criteria due to decreased set points. This diabetes can lead to severe complications for the offspring and / or for the mother. The management of a patient suffering from gestational diabetes is based on healthy diet and lifestyle advices. Iterative control of capillary glycemia is the usual way to monitor daily blood glucose. Continuous blood glucose measurement (CGM) provides reliable and comprehensive data over several days. Observing and interpreting the continuously recorded glucose concentration values should help to better understand the kinetics of glucose and to personalize the treatment. This preliminary study reports the results of 12 women with gestational diabetes and describes fluctuations of blood glucose levels all day long, particularly in the postprandial period. The CGM analysis shows that the maximum concentration of postprandial glucose is reached approximately 70 minutes after the morning and midday meals and 110 minutes after the evening meal.

La prévalence du diabète gestationnel augmente en raison d'un dépistage universel, mais aussi en raison de critères diagnostiques plus stricts, revus à la baisse. Ce diabète peut s'accompagner de complications pouvant être sévères pour l'enfant et/ou la mère. La prise en charge d'une patiente atteinte de diabète gestationnel repose sur les conseils hygiéno-diététiques adaptés et sur la surveillance des fluctuations glycémiques. En pratique habituelle, la surveillance glycémique quotidienne est réalisée via le contrôle itératif des glycémies capillaires. La mesure continue de la glycémie (MCG) offre l'avantage d'obtenir des données fiables et exhaustives sur plusieurs jours. Observer et interpréter les valeurs de concentration de glucose enregistrées de manière continue permettraient de mieux appréhender la cinétique du glucose et, idéalement, de personnaliser l'approche thérapeutique. Ce travail préliminaire rapporte les résultats observés chez 12 patientes présentant un diabète gestationnel et décrit les fluctuations du glucose au cours du nycthémère, particulièrement en période postprandiale. L'analyse de la MCG démontre que la concentration maximale de glucose postprandial est atteinte aux alentours de 70 minutes après le repas du matin et du midi et 110 minutes après le repas du soir.

[Management of gestational diabetes]. / Prise en charge du diabète gestationnel.

Pregnancy is associated with relative carbohydrate intolerance and insulin resistance. Gestational diabetes mellitus (GDM) is recognized as a risk factor for a number of adverse outcomes during pregnancy, including excessive fetal growth, increased incidence of birth trauma and neonatal metabolic abnormalities. This recognition has led to recommendations to screen all pregnant women for GDM and to treat those whose glucose tolerance tests exceed threshold criteria. Numerous epidemiological studies show that GDM affects between 1 and 25% of pregnancies, depending on the ethnicity of the population studied and the diagnostic criteria. Intervention to change lifestyle and, if maternal hyperglycemia persists, treatment with additional oral medication or insulin injections have shown to improve perinatal outcomes. Patients with GDM have a high risk of developing type 2 diabetes in the years after delivery and these women are encouraged to practice specific health behaviours (dietary habits, physical activity) during the postpartum period. The present article discusses the management of GDM in the light of data from the latest studies and international recommendations.

[Orthostatic hypotension: 2nd part. Epidemiology, complications and treatments]. / L'hypotension orthostatique: 2ème partie. Epidémiologie, complications et traitements.

Orthostatic hypotension (OH) is a rather common phenomenon in clinical practice. It may occur in 5-10 % of normal individuals, but its prevalence increases with age and various pathologies, so that it may rise above 35 % in certain subgroups of patients. OH is associated with various comorbidities, in particular cardio-cerebro-vascular accidents and falls (especially in the elderly), and may even increase mortality. It is, however, difficult to determine whether OH is simply a marker of frailty or whether it is really a risk factor. OH treatment involves physical manoeuvres or medications, which aim at inducing a peripheral vasoconstriction (midodrine, etilefrine) or an increase of circulating blood volume (9-alpha-fluohydrocortisone). However, their use should be cautious, because of a risk of arterial hypertension in supine position.

[Diagnosis of gestational diabetes]. / La vignette diagnostique de l'étudiant. Diagnostic d'un diabète gestationnel.

Gestational diabetes (GD) is a common complication of pregnancy. Its prevalence depends on the strategy used for screening and the studied population. Pregnant women with GD are at increased risk for maternal and fetal complications. The relationship between maternal blood sugar and complications is linear, without a clear threshold defining GD. Therefore, the diagnostic criteria for GD have been the subject of several controversies since many years. The choice of the one-step or two-step method, the test to be used and the cut-off levels validated to define GD are still debated. The same is true regarding a universal versus a at-risk population screening. International experts have recently proposed the use of a one-step approach with a 2-hour oral glucose tolerance test for a universal screening. The need for a better harmonization regarding the diagnosis of GD is indeed mandatory. The present article discusses both the advantages and disadvantages of the various approaches used for GD screening.

[Orthostatic hypotension: definition, symptoms, assessment and pathophysiology]. / L'Hypotension orthostatique: 1ère partie: definition, symptomatologie, évaluation et physiopathologie.

Orthostatic hypotension (OH) is defined by a drop in arterial blood pressure (BP) of at least 20 mmHg for systolic BP and 10 mmHg for diastolic BP after standing. Symptoms are generally quite typical, but may also be rather vague. Diagnosis may be easily made by the physician in his/ her office, and confirmed, if necessary, by more sophisticated measurements. Pathophysiology is generally rather complex, but mostly involves a defect in the autonomic nervous system, in its sympathetic component. Failure of peripheral vasoconstriction seems to play a more important role than the defect in reflex tachycardia. Causes of OH are multiples. OH may occur in healthy subjects, when exposed to exceptional circumstances, but is more generally associated with various diseases, either neurological disorders or pathologies characterized by hypovolemia. Medications can also aggravate the risk of OH, among which some antihypertensive or psychotropic agents. Elderly people, especially frailty subjects, are exposed to a high risk of OH, whose origin is often multifactorial, and this complication may have serious medical consequences.

[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.

[Screening strategy and diagnostic criteria for gestational diabetes. Proposals of the GGOLFB]. / Stratégie de dépistage et critères diagnostiques du diabète gestationnel. Propositions du GGOLFB.

For nearly 50 years, the strategy of screening and the diagnostic criteria for gestational diabetes have been the subject of endless controversies. They differ between countries and from one center to another, mainly because of the lack of hard data allowing to define glycemic thresholds at which a therapeutic management is needed. Recently, a large observational study has demonstrated the existence of a robust relationship between maternal blood sugar and several fetomaternal perinatal complications. This relationship is linear, with no clear threshold that would define gestational diabetes unambiguously. Meanwhile, two randomized intervention trials have shown that the therapeutic management of mild gestational diabetes was associated with improved perinatal outcomes. Based on these data, the " International Association of Diabetes and Pregnancy Study Group "(IADPSG) released new recommendations on screening methods and diagnostic criteria for gestational diabetes. Although already endorsed by several international associations and implemented in some countries, these recommendations still raise questions and criticisms. This is why the "Groupement des Gynécologues Obstétriciens de Langue Française de Belgique " (GGOLFB) organized a meeting between diabetologists and gynecologists which allowed to reach a consensus on the strategy that we intend to implement in our respective centers. The purpose of this paper is to briefly overview the recent advances in gestational diabetes and more particularly to make our key conclusions known to the medical community. This will enable the standardization of the management of gestational diabetes in the French-speaking part of Belgium.

[Screening strategy and diagnostic criteria for gestational diabetes. Proposals of the GGOLFB]. / Stratégie de dépistage et critères diagnostiques du diabète gestationnel. Propositions du GGOLFB.

For nearly 50 years, the strategy of screening and the diagnostic criteria for gestational diabetes have been the subject of endless controversies. They differ between countries and from one center to another, mainly because of the lack of hard data allowing to define glycemic thresholds at which a therapeutic management is needed. Recently, a large observational study has demonstrated the existence of a robust relationship between maternal blood sugar and several fetomaternal perinatal complications. This relationship is linear, with no clear threshold that would define gestational diabetes unambiguously. Meanwhile, two randomized intervention trials have shown that the therapeutic management of mild gestational diabetes was associated with improved perinatal outcomes. Based on these data, the "International Association of Diabetes and Pregnancy Study Group" (IADPSG) released new recommendations on screening methods and diagnostic criteria for gestational diabetes. Although already endorsed by several international associations and implemented in some countries, these recommendations still raise questions and criticisms. This is why the "Groupement des Gynécologues Obstétriciens de Langue Française de Belgique" (GGOLFB) organized a meeting between diabetologists and gynecologists which allowed to reach a consensus on the strategy that we intend to implement in our respective centers. The purpose of this paper is to briefly overview the recent advances in gestational diabetes and more particularly to make our key conclusions known to the medical community. This will enable the standardization of the management of gestational diabetes in the French-speaking part of Belgium.

[Hypertension and diabetes: about a common but complex association]. / Hypertension et diabète: à propos d'une association commune mais complexe.

Both diabetes mellitus and arterial hypertension are commonly observed in a single patient. However, the relationship between these two entities is rather complex and there is a great heterogeneity regarding the underlying pathophysiological mechanisms and the clinical presentations. These particularities may have important consequences from a therapeutic point of view, as far as blood pressure targets or even pharmacological strategies are concerned. The present article will discuss the various causes of hypertension in the different types of diabetes, the different forms of hypertension in the diabetic patient, the modalities of treating hypertension in presence of various specific complications (metabolic syndrome, coronary heart disease or renal impairment), and the specificities when hypertension is associated with diabetic cardiovascular autonomic neuropathy.

[Relationships between baroreflex gain and pulsatile stress in type 1 diabetic patients]. / Relations entre gain baroréflexe et stress pulsatile chez le patient diabétique de type 1.

AIM OF THE STUDY: Cardiovascular autonomic neuropathy (CAN) and early arterial stiffness are frequent complications in type 1 diabetes. The aim of our work is to study the relationships between CAN (estimated by baroreflex gain calculation) and arterial stiffness (estimated by pulsatile stress) in type 1 diabetic patients. PATIENTS AND METHODS: In a cross-sectional study, we calculated baroreflex gain and pulsatile stress in 167 type 1 diabetic patients and 160 matched non-diabetic subjects whose blood pressure was continuously monitored with a Finapres(®) device in a postural test (squatting test). The baroreflex gain was calculated by plotting the pulse intervals (R-R) against systolic blood pressure values during the transition phase from squatting to standing. Pulsatile stress was estimated by the pulse pressure×heart rate product. In a longitudinal study, the baroreflex gain and pulsatile stress were calculated before and after a mean follow-up of 79±33 months in type 1 diabetic patients. RESULTS: Cross-sectional data showed a decrease in baroreflex gain and an increase in pulsatile stress in type 1 diabetic patients versus the matched non-diabetic subjects. A significant correlation between the baroreflex gain and pulsatile stress was present. Type 1 diabetic patients with lower baroreflex gain had a higher value of pulsatile stress when compared to those with higher baroreflex gain. During follow-up, a significant reduction in baroreflex gain (but without significantly increased pulsatile stress) was observed. A univariate analysis showed that the decrease of the baroreflex gain is not correlated with the time interval between the two tests, neither type 1 diabetes duration nor mean glycated hemoglobin values, but significantly with the pulsatile stress increase. CONCLUSION: In type 1 diabetic patients, the baroreflex gain is decreased and the pulsatile stress is increased when these markers are compared to age-matched non-diabetic subjects. There is a relationship between indices of CAN and arterial stiffness. Nevertheless, the baroreflex gain (marker of CAN) is impaired earlier than the pulsatile stress in this type 1 diabetic population with inadequate glycaemic control.