Professional practices in the management of adrenal insufficiency in two tertiary referral hospitals (Tunis, Tunisia).

BACKGROUND: Adrenal insufficiency (AI) is a rare and life-threatening disease. Glucocorticoid replacement therapy and patient education are crucial. Few is known about physician practice in this topic. AIMS: To describe physician practice in the management of AI and to identify the associated factors. METHODS: the physicians, all grades and specialties, from two university hospitals in Tunis, were invited to respond to a paper-based 16- multiple choice item-questionnaire about the management of AI and the prevention of acute AI. Each question was scored 1 if correct or 0 if incorrect. The global score was calculated by adding the score of the first 15 questions. RESULTS: 200 physicians responded to the questionnaire, sex ratio: 0.47, mean age: 29.0 ± 5.8 years (24 - 60). The overall rate of correct answers was 59.6%. The rate of correct responses was good for the type of replacement therapy (92%), the lifelong duration of treatment (88%), the symptoms of overtreatment (73.5%), the type of diet indicated (77%), and the necessity of special measures during the peri operative period (100%). However, the rate of correct responses was low for the half-life of hydrocortisone (12.5%), biological signs suggesting acute AI (17.5%), situations during which an increase in the dose of glucocorticoid is required (26.5%) and the risks of intermittent fasting (2%). Endocrinology specialty and overall medical specialties were independently associated with a better global score. CONCLUSION: physician practice in the management of AI need to be improved.

Blood pressure evaluated by 24 h ambulatory blood pressure monitoring in Ramadan-fasting patients with corticotrope deficiency.

PURPOSE: The risks of Ramadan fasting on blood pressure (BP) in patients with adrenal insufficiency are unknown. This study aimed to evaluate the levels of BP and particularly the risk for hypotension during a fasting day compared with a nonfasting day in patients with corticotrope deficiency. METHODS: A prospective case-crossover study on 28 patients with known and treated corticotrope deficiency who were fasting the month of Ramadan. Clinical (eating and sleeping habits, abnormal symptoms, weight, height, and BP) and paraclinical (creatinine, sodium, and cortisol) data were collected. Patients had a 24 h ambulatory BP monitoring during a Ramadan fasting day then again during a nonfasting day. RESULTS: The data of 25 patients were analyzed; 20 women, median age: 40 years (IQR, 22.5-45.5), median duration of the disease: 6 years (IQR, 2.5-12). The prevalence of hypotension did not differ between the fasting day and the nonfasting day. Hour by hour BP levels comparison showed that both systolic and diastolic BP were significantly lower at 2.00 p.m. during fasting. BP variability was significantly lower during the fasting period compared with the same period during the nonfasting day. CONCLUSIONS: Fasting was not associated with an increased risk for hypotension in patients with known and treated corticotrope deficiency.

Prednisolone or hydrocortisone replacement in patients with corticotrope deficiency fasting during Ramadan result in similar risks of complications and quality of life: a randomized double-blind controlled trial.

PURPOSE: The aims of the study were to compare the risk of complications and the quality of life in patients with corticotrope deficiency, who fasted during Ramadan. Both hydrocortisone and prednisolone were compared as treatments. METHODS: A randomized double-blind crossover clinical trial conducted in the department of Endocrinology of the University Hospital la Rabta in Tunis, during Ramadan 2018, on 53 patients with known corticotrope deficiency treated with hydrocortisone 20 mg per day and who were willing to fast during Ramadan. Patients were randomized into two groups; AB that received hydrocortisone twice daily for 14 days then prednisolone once daily with a placebo for 14 days and group BA that received the two treatments in the reverse order. Patients had to complete a daily follow-up sheet about their eating and sleeping habits, the occurrence of complications and blood glucose monitoring and also to respond to the AddiQoL questionnaire at the end of each treatment period. RESULTS: Fifty patients' data were analyzed; 29 men, mean age: 42.4 ± 13.3 years, mean duration of the disease: 8.1 ± 7.6 years. The frequency of complications, mean blood glucose levels and the quality of life did not differ on hydrocortisone compared to prednisolone after adjustment for the sequence of the treatment. CONCLUSIONS: the risks of Ramadan fasting in patients with corticotrope deficiency were the same on hydrocortisone or prednisolone.

The Role of Genetic Variants (rs869109213 and rs2070744) Of the eNOS Gene and BglII in the α2 Subunit of the α2ß1 Integrin Gene in Diabetic Retinopathy in a Tunisian Population.

Purpose: In this study, we investigated the association of two polymorphisms (rs869109213 and rs2070744) in the eNOS gene and one polymorphism BglII in the α2ß1 integrin gene (ITGA2) with the risk of diabetic retinopathy (DR) in a Tunisian population. Methods: The study investigated of 110 type 2 diabetes mellitus (T2DM) and 127 DR patients. The genotypes of the eNOS 4b/4a (rs869109213) and -786T/C (rs2070744) polymorphisms and of the BglII polymorphism of ITGA2 were studied using the PCR or PCR-RFLP method. Results: The genotype distributions of the two polymorphisms in eNOS 4b4a and eNOS (-786T/C) were significantly different between T2DM and DR patients (p < .004 and p = .033, respectively). These polymorphisms were associated with the risk of DR (OR = 2.65, 95%CI [1.45-4.84], p = .002) for the eNOS 4b4a genotype and (OR = 2.43, 95%CI [1.06 - 5.56], p = .036) for the CC genotype of the eNOS gene (-786T/C). Similarly, the genotype distribution of the BglII polymorphism was significantly different between the two groups studied (p = .037). This polymorphism was associated with an increased risk of DR (OR = 4.03, 95% CI [1.17 - 7.85], p = .022) for BglII(+/+). Conclusion: The present study suggests that the polymorphisms 4b4a and -786T/C in the eNOS gene might be associated with DR. In addition, the BglII polymorphism in the ITGA2 gene was a risk factor for DR.

The A445C Variant in Apelin Receptor and Diabetic Retinopathy in Tunisian Patients.

BACKGROUND: Apelin and apelin receptor (APLN/APLNR) are involved in the retinal neovascularization of diabetic retinopathy (DR). METHODS: This study investigated the impact of the APLNR A445C variant on the risk of DR in a sample of the Tunisian population (100 patients with DR and 105 healthy controls) using PCR-RFLP. RESULTS: The genotype frequencies of the APLNR A445C variant were not significantly different between the patient and control groups. The genotype was not associated with DR (OR = 1.49; 95% CI [0.49 - 4.48], p = 0.47 for the AC heterozygous genotype and OR = 1.57; 95% CI [0.43 - 5.71], p = 0.49 for the CC homozygous genotype). Furthermore, the clinical and biochemical parameters according to the APLNR A445C genotypes revealed that only total cholesterol (TC) was significantly higher in the DR group with the CC genotype compared to the AA genotype (p < 0.02). CONCLUSIONS: The APLNR A445C polymorphism was not associated with DR in a sample of the Tunisian population, but the CC genotype carrier patients with DR had a high TC concentration.

Ramadan fasting in patients with adrenal insufficiency.

AIM: The risks of fasting during Ramadan in patients with adrenal insufficiency are unknown. The aims of this study were to evaluate these risks in such patients, to determine the risk factors and finally to set some recommendations. METHODS: It is a cross-sectional study about 180 patients with known and treated adrenal insufficiency. The patients responded to a 14-item questionnaire concerning their knowledge about the disease and fasting during the last month of Ramadan. RESULTS: There were 132 women and 48 men. The mean age was 47.6 ± 15.0 years (14-79). One hundred and thirty eight patients (76.7 %) were advised by their physician not to fast. Ninety-one patients (50.5 %) tried to fast. Complications occurred in 61 cases (67.0 %): asthenia in 88.5 % of cases, intense thirst in 32.8 %, symptoms of dehydration in 49.2 % and symptoms of hypoglycaemia in 18 %. One patient was hospitalized. Fifty-five patients (60.4 %) were able to fast for the whole month. Age, gender, duration of the disease, its primary origin, associated hypothyroidism, diabetes mellitus, hypertension or diabetes insipidus and daily dose of hydrocortisone did not significantly differ between fasters and non-fasters, full-month-fasters and partial-month-fasters, and fasters with complications and fasters without complications. The frequency of adequate knowledge about the disease was significantly higher in full-month-fasters vs. partial-month-fasters, and in fasters without complications vs. those with complications. CONCLUSION: In patients with adrenal insufficiency, fasting can cause complications especially if the level of knowledge about the disease is low.