Recommendations for management of diabetes and its complications during Hajj (Muslim Pilgrimage) - 2024 update.

Hajj is an obligatory duty for all healthy adult Muslims once in the lifetime subjected to the ability. Considering the 10.5 % global prevalence of diabetes coupled with the numbers of Muslims performing the Hajj, ∼ 1.8 million in 2023, it is estimated that Muslims with diabetes performing Hajj may exceed 340,000 this year. During Hajj the pattern and amount of their meal, fluid intake and physical activity are markedly altered. Many people with diabetes insist on doing the Hajj duty, thereby creating a medical challenge for themselves and their health care providers. It is therefore important that medical professionals be aware of the potential risks that may be associated with Hajj. People with diabetes may face many health hazards during Hajj including but not limited to the killer triad which might occur during Hajj: Hypoglycemia, Foot injury and Infections. Many precautions should be taken to prevent and treat these potentially serious complications. Risk stratification, medication adjustments, proper clinical assessment, and education before doing Hajj are crucial.

Analysis of disease characteristics of a large patient cohort with congenital generalized lipodystrophy from the Middle East and North Africa.

BACKGROUND: Congenital generalized lipodystrophy (CGL) is a rare inherited disease characterized by a near-total absence of adipose tissue and is associated with organ system abnormalities and severe metabolic complications. Here, we have analyzed the disease characteristics of the largest CGL cohort from the Middle East and North Africa (MENA) who have not received lipodystrophy-specific treatment. METHODS: CGL was diagnosed clinically by treating physicians through physical assessment and supported by genetic analysis, fat loss patterns, family history, and the presence of parental consanguinity. Data were obtained at the time of patient diagnosis and during leptin-replacement naïve follow-up visits as permitted by available medical records. RESULTS: Data from 43 patients with CGL (37 females, 86%) were collected from centers located in eight countries. The mean (median, range) age at diagnosis was 5.1 (1.0, at birth-37) years. Genetic analysis of the overall cohort showed that CGL1 (n = 14, 33%) and CGL2 (n = 18, 42%) were the predominant CGL subtypes followed by CGL4 (n = 10, 23%); a genetic diagnosis was unavailable for one patient (2%). There was a high prevalence of parental consanguinity (93%) and family history (67%) of lipodystrophy, with 64% (n = 25/39) and 51% (n = 20/39) of patients presenting with acromegaloid features and acanthosis nigricans, respectively. Eighty-one percent (n = 35/43) of patients had at least one organ abnormality; the most frequently affected organs were the liver (70%, n = 30/43), the cardiovascular system (37%, n = 16/43) and the spleen (33%, n = 14/43). Thirteen out of 28 (46%) patients had HbA1c > 5.7% and 20/33 (61%) had triglyceride levels > 2.26 mmol/L (200 mg/dl). Generally, patients diagnosed in adolescence or later had a greater severity of metabolic disease versus those diagnosed during childhood; however, metabolic and organ system abnormalities were observed in a subset of patients diagnosed before or at 1 year of age. CONCLUSIONS: This analysis suggests that in addition to the early onset of fat loss, family history and high consanguinity enable the identification of young patients with CGL in the MENA region. In patients with CGL who have not received lipodystrophy-specific treatment, severe metabolic disease and organ abnormalities can develop by late childhood and worsen with age.

Radiological predictive remission factors of pulmonary involvement in systemic sarcoidosis: a computed tomography scan study.

INTRODUCTION: As little is known about the prognostic value of CT scan findings at onset in patients presenting with sarcoidosis, we aimed to identify factors independently associated with radiological remission of pulmonary involvement in systemic sarcoidosis on CT scan findings. METHODS: We conducted a retrospective descriptive and analytic study of patients with a biopsy proven systemic sarcoidosis. We compared patients on radiological remission (group 1) to those on stabilization or progression (group 2). Multivariate analysis of variables significantly associated with radiological remission in univariate analysis was performed using binary logistic regression. RESULTS: Out of 65 records of systemic sarcoidosis, 43 were analyzed. 18.6% where male and 81.6% female with a sex-ratio of 0.22 and a mean age at diagnosis of 47.2 ±13.6 years. We found atypical lesions in CT scan findings in 16 patients (37.2%). Comparative pulmonary CT scan findings at admission and at 12 months follow-up revealed 13 patients (30.2%) in remission (group1) and 30 patients in radiological stabilization or progression (group 2). On multivariate analysis, lymphopenia, calcifications, and typical CT scan findings at presentation were predictive factors of remission of pulmonary involvement in systemic sarcoidosis (aOR=27.57; 95%IC=2.67-284.63; p=0.005) (aOR= 37.2; 95%IC= 2.08-663.89; p= 0.014) (aOR=47.1; 95%IC= 1.79-1238.7; p=0.021) respectively. CONCLUSION: In patients with systemic sarcoidosis with no lymphopenia at onset or calcifications or typical CT scan findings at presentation, we suggest a close follow-up as well as an intensive treatment.

Turner syndrome: results of the first Tunisian study group on Turner syndrome (TuSGOT).

OBJECTIVES: Early diagnosis in Turner syndrome is desirable to optimize growth and puberty and yet, it is often made late. Here, we aim to identify age at diagnosis, clinical features at presentation and potential strategies to improve the care of TS girls. METHODS: Retrospective study, including patients from 14 care centers across Tunisia including neonatal and pediatric care units, adult endocrinology and genetics departments. RESULTS: We identified 175 patients with TS, karyotype showing 45, xmonosomy in 83(47.4 %) with mosaicism in 37(20 %). Mean ± SD, median (range) age at diagnosis available in 173 patients was 13 ± 9.2,12 (birth-48) years. The diagnosis was antenatal in 4(2.3 %), from birth-2 years in 14 (8 %)with lymphoedema (8)and dysmorphic features (9),2-12 years in 53 (35.5 %) including 35 with short stature, 13-18 years in 43(28.8 %) with short stature(28) and delayed puberty(14) and 35(23.5 %) after 18 years, related to ovarian insufficiency (20) and short stature (11). The associated malformations were cardiac in 14 (12.8 %), renal in 22 (19.6 %). A total of 56 girls (32 %) had proven gonadal dysgenesis and 13 (7 %) had otological problems. Parental height was available in 71 girls (40 %) of whom 59 were below the lower end of parental target range (LTR) (83 %). CONCLUSIONS: This first Tunisian multicenter study, the first African of its kind, reveals that more than half of Turner syndrome cases are diagnosed after the age of 12 years. Subsequently, national strategies for an earlier TS diagnosis are needed such as measuring and plotting parental heights as well as introducing a systematic height screening at 5 years in Tunisia with a view to carrying out a re-audit in five years' time.

Simultaneous testicle and epididymis vasculitis revealing granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing granulomatous vasculitis, which predominantly affects small-sized blood vessels. We aimed to report a case of GPA involving testicles and epididymis taken for malignancy. A 75-year-old patient was admitted for a painful left testicular mass. There was no extra urogenital manifestations on examination and the workup was unremarkable. Histological findings after orchidectomy revealed granulomatous inflammation of the testis and epididymis with fibrinoid necrosis and necrotic vasculitis consisting with the diagnosis of GPA. Further investigations regarding ear, nose, throat, pulmonary, and renal involvement were negative. Proteinase 3 antineutrophil cytoplasmic antibodies (PR3-ANCA) test was negative. Furthermore, infectious diseases especially tuberculosis were ruled out. Based on histopathological findings, limited GPA was diagnosed. The patient was treated with methotrexate and prednisone with good outcome. There was no relapse after 1 year of follow-up. Isolated urogenital involvement may occur at the onset of GPA and can be taken for malignancy. Histopathological findings are the gold standard for the diagnosis. Treatment is based on steroids and immunosuppressive drugs.

Acromegaly: an endocrine pathology with serious consequences / L'acromégalie : une pathologie endocrinienne à lourdes conséquences

Acromegaly is a rare endocrine disorder leading to an acquired physical disfigurement and multisystem damage. It is caused in over 95% of cases by a secreting pituitary adenoma. Latency period between disease onset and diagnosis is mainly 10 years due to progressive chronic evolution and exposure to high levels of GH and IGF-1. Here we present a case of acromegaly with over 25 years of diagnostic delay in 69-years-old male with typical features and recurrent urolithiasis. Biochemical diagnosis was confirmed by high levels of IGF-1and lack of suppression of GH during an oral glucose load. Imaging and histological study revealed a co-secreting GH/ prolactine macroadenoma. After three months of complete transphenoidal surgical resection, biochemical remission was not obtained and the patient was treated by a somatostatin receptor ligand. Based on this severe case with atypical manifestations, the diagnosis of acromegaly should be always considered.

L'acromégalie est une maladie endocrinienne rare caractérisée par un syndrome dysmorphique acquis et des atteintes multi-systémiques invalidantes en rapport, dans 95 % des cas, avec un macroadénome hypophysaire. La lente progression et l'exposition chronique aux fortes concentrations de l'hormone de croissance (Growth Hormone : GH) et de l'Insuline Growth Factor-1 (IGF-1) expliquent le retard du diagnostic de 10 ans en moyenne. Nous rapportons le cas d'une acromégalie chez un sujet âgé de 69 ans diagnostiqué après plus de 25 ans d'installation du syndrome dysmorphique et de lithiases urinaires récidivantes. Le diagnostic a été confirmé biologiquement par des concentrations très élevées et non freinables de GH et par la présence d'un macroadénome hypophysaire exprimant doublement la GH et la prolactine. Après résection chirurgicale complète, l'évaluation biologique n'a pas objectivé de rémission, d'où le recours à un traitement adjuvant par un analogue de la somatostatine. En présence de multiples atteintes atypiques et sévères comme chez ce patient, le diagnostic d'acromégalie doit toujours être évoqué.

Knowledge gaps and perceptions of future research directions on management of diabetes during Ramadan fasting: An online survey of physicians.

OBJECTIVES: Current knowledge and research on diabetes and Ramadan form the basis for evidence-based clinical practice. In this context, we aimed to explore physicians' perceptions of current knowledge gaps about research fasting (RF), barriers to, and foreseeable directions for advancement of the field. METHODS: We conducted an online survey of a convenience sample of 260 physicians from 27 countries. The survey questionnaire addressed three main domains: perceived current knowledge gaps and unmet needs in research about RF and diabetes, barriers to the conduct of research, and future directions for furthering the evidence in this field. RESULTS: Majority of respondents (65.7%) were senior physicians in adult endocrinology/diabetes (45.9%) working at tertiary centers (65.2%). The majority (67.3%) reported seeing an average of 20+ patients with diabetes weekly and felt "very or fairly confident" in managing diabetes during RF (67.7%). The knowledge gaps identified were the management of high-risk patients with diabetes (54.1%), such as renal impairment (59.8%), and pregnancy (61.5%). The main barriers to research were lack of adequate funding to academic centers (75.7%) and lack of interest of institutions in the subject (64.6%). Future efforts should be directed at the conduct of large epidemiological studies (49.5%) or double-blinded, placebo-controlled clinical trials (48.6%) to address the former gaps. Research findings should be widely disseminated via hands-on workshops (recommended by 70.3% of respondents) or international conferences (61.2%). CONCLUSIONS: There is a wide agreement regarding the knowledge gaps in the management of diabetes during RF. Future efforts should focus on addressing these critical deficiencies.

Simulation Based Learning in internal medicine students.

INTRODUCTION: Few experiences have been reported in simulation-based learning (SBL) in internal medicine. AIM: To assess the SBL impact in internal medicine learning on learners' perception, knowledge acquisition, and cognitive and communication skills evaluation. METHODS: A prospective observational study conducted in the Simulation Center at the Faculty of Medicine of Monastir between November 2018 and March 2019. High fidelity sessions were intended for lupus flare diagnosis and a standardized patient session for therapeutic education of patients on antivitamin K treatment. RESULTS: A total of 118 third-year undergraduate medical learners split into 9 groups attended 9 SBL sessions. Regarding learners' perception, gain in communication was felt among 117 learners (99.1%) and gain in confidence among 116 of them (98.3%). As for SBL impact on knowledge acquisition, the overall median pre and post-test scores were 5.76 / 10 (4.61-6.92) and 7.69 / 10 (6.92-9.23) respectively (p = 10-3). The median overall improvement score was 2.3(0.76-3.07). Assessing learners' skills made it possible to highlight certain learners' shortcomings which we focused on during debriefing. CONCLUSION: According to the current study, SBL was associated with a high level of learners' satisfaction and was effective in optimizing knowledge and communication in lupus flare diagnosis and antivitamin K management.

Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus.

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The American Diabetes Association/European Association for the Study of Diabetes consensus recommendations emphasize the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycemia risk, weight issues and costs. Structured education and pre-Ramadan counseing are key components to successful management of patients with diabetes. These should cover important aspects like glycemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The decision cycle adapted for the specific situation of Ramadan provides an aid for such an assessment. Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes. Hypoglycemia is a common concern during Ramadan fasting. To prevent hypoglycemic and hyperglycemic events, we recommend the adoption of diabetes self-management education and support principles. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycemic and hyperglycemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier.

Erdheim-chester disease revealed by diabetes insipidus.

Erdheim-Chester disease (ECD) is a very rare and aggressive form of non-Langerhans histiocytosis with unclear pathogenesis. Because of the heterogeneity of clinical presentation, diagnosis is often challenging and delayed. Currently, Interferon alpha is the first line treatment that is associated with a better survival. The prognosis is relatively poor, especially in case of neurological and cardiovascular involvement. Herein, we report the case of a 64-year-old Tunisian female patient presenting an aggressive form of ECD revealed by diabetes insipidus and cerebellar ataxia with a diagnosis delay of 4 years. The assessment of disease extent had also shown associated asymptomatic cardiac and bone involvement. Pegylated Interferon alpha was started at high dose allowing disease stabilization. This case illustrates that physicians should be aware of the heterogeneous manifestations of ECD in order to insure an early diagnosis and treatment. Long-term and regular follow-up is crucial because of the risk of disease progression.

A case of Kallmann syndrome associated with a non-functional pituitary microadenoma.

Kallmann syndrome (KS) is a form of hypogonadotropic hypogonadism in combination with a defect in sense of smell, due to abnormal migration of gonadotropin-releasing hormone-producing neurons. We report a case of a 17-year-old Tunisian male who presented with eunuchoid body proportions, absence of facial, axillary and pubic hair, micropenis and surgically corrected cryptorchidism. Associated findings included anosmia. Karyotype was 46XY and hormonal measurement hypogonadotropic hypogonadism. MRI of the brain showed bilateral agenesis of the olfactory bulbs and 3.5 mm pituitary microadenoma. Hormonal assays showed no evidence of pituitary hypersecretion. LEARNING POINTS: The main clinical characteristics of KS include hypogonadotropic hypogonadism and anosmia or hyposmia.MRI, as a non-irradiating technique, should be the first radiological step for investigating the pituitary gland as well as abnormalities of the ethmoid, olfactory bulbs and tracts in KS.KS may include anterior pituitary hypoplasia or an empty sella syndrome. The originality of our case is that a microadenoma also may be encountered in KS. Hormonal assessment indicated the microadenoma was non-functioning. This emphasizes the importance of visualizing the pituitary region in KS patients to assess for hypoplastic pituitary malformations or adenomas.

Cardiac and vascular complications of Behçet disease in the Tunisian context: clinical characteristics and predictive factors.

BACKGROUND: Cardiac and vascular involvement in Behçet disease (BD), also referred as vasculo BD, is frequent. We aimed to describe clinical characteristics, predictive factors and management of vasculo BD in the Tunisian context. METHODS: We retrospectively studied 213 records of all BD patients followed between January 2004 and May 2016 in the Internal Medicine Department and who fulfilled the ISGBD criteria. We described first clinical features of BD with cardiac and vascular involvement then predictive factors were studied in univariate then multivariate analysis. RESULTS: Among the 213 patients, 64 (30%) were diagnosed as having vasculo BD. The mean age at diagnosis was 31.5 years. About 81.25% of them were males and 18.75% females. Vascular involvement associated or not with cardiac involvement was found in 64 patients (30%). Deep venous thromboses are most common (62.5%) compared with superficial ones (23.4%), pulmonary arterial thrombosis (14.1%) or aneurysms (9.4%). Cardiac involvement is ranging from pericarditis (1.6%) to intra cardiac thrombosis (3.1%) and myocardial infarction (1.6%). Predictive factors associated with cardiac and vascular involvement in BD are male gender (OR = 3.043, 95% CI = 1.436-6.447, p = 0.004), erythema nodosum (OR = 4.134, 95% CI = 1.541-11.091, p = 0.005) and neurologic involvement (OR = 2.46, 95% CI = 1.02-5.89, p = 0.043). CONCLUSION: Cardiac and vascular involvement in BD is frequent in the Tunisian context with a broad spectrum of manifestations ranging from vascular involvement to cardiac one. Male gender, patients with erythema nodosum or neurologic involvement are prone to develop cardiac or vascular features of BD needing therefore a close monitoring.

Hughes-Stovin syndrome revealing the presence of Behçet's Disease.

BACKGROUND: Hughes-Stovin Syndrome (HSS) is a rare clinical disorder characterized by deep venous thrombosis and multiple pulmonary and/or bronchial aneurysms. Aneurysms in systemic circulation can also be seen. CASE PRESENTATION: We report the first case of HSS with aortic aneurysm in a 55-year-old man who initially presented with deep venous thrombosis. The diagnosis of HSS revealing Behçet's disease was made given the history of recurrent oral and genital ulcers. Treatment consisted of 3 daily pulses of methylprednisolone (1g) followed by oral prednisone (1mg/kg daily) and 6 monthly pulses of cyclophosphamide. Oral anticoagulation treatment was held 3 months and then was stopped with good outcome. CONCLUSION: Systemic aneurysms in Hughes Stovin is a worth knowing complication which may reveal Behçet's disease.

One-Year Outcome of Intensive Insulin Therapy Combined to Glucose-Insulin-Potassium in Acute Coronary Syndrome: A Randomized Controlled Study.

BACKGROUND: A number of factors may offset the cardioprotective effects of glucose-insulin-potassium (GIK) on outcome of patients with acute coronary syndrome, such as hyperglycemia induced by this cocktail infusion. We performed a study to evaluate the effect of intensive insulin therapy in association with GIK on 1-year outcome in patients hospitalized for acute coronary syndrome. METHODS AND RESULTS: In a randomized prospective controlled trial we included 772 patients with non-ST-segment elevation acute coronary syndrome. Patients were randomized into 3 groups: GIKI2 group, who received GIK with intensive insulin therapy for 24 hours; GIK group, who received GIK with nonintensive insulin therapy; and control group, who received usual care. The primary outcome criteria were the rates of major cardiovascular events combining death, reinfarction, and stroke rate at 1 year. In addition, we measured platelet function assay-100 and plasminogen activator inhibitor-1 at admission and 24 hours later. Based on an intention-to-treat analysis, major cardiovascular events at 1 year was 12.8% in the GIKI2 group, 15.5% in the GIK group, and 20.5% in the placebo group; the difference was significant between the GIK2 and control groups (P=0.01). Platelet function assay-100 at 24 hours decreased significantly from baseline in the control group but not in the GIKI2 group. Plasminogen activator inhibitor-1 decreased significantly in the GIKI2 group but significantly increased in the control group. Minor hypoglycemic events were more frequent in the GIKI2 group compared with other groups. CONCLUSIONS: GIKI2 led to improvement of 1-year outcome rates in patients with non-ST-segment elevation acute coronary syndrome. This beneficial effect was associated with a decrease in platelet reactivity and an increase on fibrinolysis tests. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00965406.

Does Lipid Profile Affect Thrombin Generation During Ramadan Fasting in Patients With Cardiovascular Risks?

There is evidence that diet and variation in lipid metabolism can influence blood coagulation, but little is known about the effect of Ramadan fasting on plasmatic coagulation pattern. We investigated the effect of Ramadan fasting on thrombin generation (TG) in patients with cardiovascular disease (CVD) risks, and we aimed to assess the effect of lipid profile on TG parameters. The study was conducted in 36 adults having at least 2 CVD risks and in 30 healthy controls. Coagulation pattern was assessed by both classical clotting times and TG test. A complete lipid profile was performed simultaneously. Patients were invited 2 times: 1 week before Ramadan and during the last week of the Ramadan. The TG parameters were not different in patients with CVD risks compared to healthy controls. Fasting had no effect on plasmatic coagulation parameters and on TG profile. Individual analysis of the mean rate index (MRI) of TG revealed 3 groups: group 1 with no modification of MRI, group 2 with a significant increase in MRI (81.64 nM/min vs 136.07 nM/min; P < .001), and group 3 with a significant decrease in MRI (125.27 nM/min vs 73.18 nM/min; P = .001). Only in group 2, a significant increase was observed in total cholesterol and low-density lipoprotein cholesterol. Changes in lipid profile during Ramadan fasting did not influence the global coagulation pattern in patients with CVD risks. Whereas, a significant increase in the propagation phase of TG was associated with a significant increase in cholesterol levels, which was not found with the other TG parameters.

An acute adrenal insufficiency revealing pituitary metastases of lung cancer in an elderly patient.

Metastases of solid tumors to the pituitary gland are often asymptomatic or appereas as with diabetes insipid us. Pituitary metastases more commonly affect the posterior lobe and the infundibulum than the anterior lobe. The presentation with an acute adrenal insufficiency is a rare event. A 69-year-old men presented with vomiting, low blood pressure and hypoglycemia. Hormonal exploration confirmed a hypopituitarism. Appropriate therapy was initiated urgently. The hypothalamic-pituitary MRI showed a pituitary hypertrophy, a nodular thickening of the pituitary stalk. The chest X Rays revealed pulmonary opacity. Computed tomography scan of the chest showed a multiples tumors with mediastinal lymphadenopathy. Bronchoscopy and biopsy demonstrated a pulmonary adenocarcinoma. Hence we concluded to a lung cancer with multiple pituitary and adrenal gland metastases. This case emphasizes the need for an etiological investigation of acute adrenal insufficiency after treatment of acute phase.

[Late-onset pituitary stalk interruption syndrome (PSIS)]. / Syndrome d'interruption de la tige pituitaire à révélation tardive.

Pituitary stalk interruption syndrome is a fairly common cause of the deficiency of Growth Hormone and hypopituitarism often revealed in the neonatal period and childhood. This observation illustrates the peculiarities of a late clinical onset of this syndrome. We report a case of a 17-year-old patient hospitalized for primary amenorrhoea and impuberism. She had no history of neonatal incident. Clinical examination revealed severe growth retardation Hypophysiogramme showed complete hypopituitarism without diabetes insipidus. Magnetic resonance imaging revealed pituitary stalk interruption and an ectopic posterior pituitary gland. Kidney malformation was objectified, which is in favour of a congenital malformative origin of this syndrome. Hormone replacement was administered to this patient. This late-onset form emphasizes the need for early diagnosis of impuberism and/or stunting, revealing a potentially very serious pathology.

Obstructive sleep apnea presenting as pseudopheochromocytoma.

A 52-year-old female with a history of poorly controlled resistant hypertension was admitted to our hospital with severe hypertension. She had a history of fatigue and intermittent episodes of palpitations. Laboratory evaluation was significant for elevated 24-h urinary catecholamine levels (3,5 times the upper normal levels). This case was presenting with a clinical and biochemical picture indistinguishable from that of pheochromocytoma. However, neither computed tomography nor meta-iodo-benzyl-guanidine scintigraphy detected any catecholamine-producing tumor in or outside the adrenal glands. Our patient was screened with full polysomnography because of heavy snoring, daytime somnolence and obesity. It revealed severe obstructive sleep apnea syndrome. After three months of continuous positive airway pressure therapy, the patient experienced resolution of his presenting symptoms, improved blood pressure control and normalization of his urinary catecholamine levels. This case highlights sleep disordered breathing as a potentially reversible cause of pseudo-pheochromocytoma.

Successful switch from insulin to oral sulfonylurea therapy in HNF1A-MODY Tunisian patient with the P291fsinsC mutation.

The hot spot mutation P291fsinsC was identified for the first time in a 26 years old Tunisian woman. The low serum level of high C-reactive protein was helpful to target the HNF1A gene. Due to the molecular diagnosis, the change from insulin to sulfonylurea therapy was performed successfully.

Clinical experience with insulin detemir, biphasic insulin aspart and insulin aspart in people with type 2 diabetes: Results from the Central and Southern Tunisia cohort of the A1chieve study.

BACKGROUND: The A1chieve, a multicentric (28 countries), 24-week, non-interventional study evaluated the safety and effectiveness of insulin detemir, biphasic insulin aspart and insulin aspart in people with T2DM (n = 66,726) in routine clinical care across four continents. MATERIALS AND METHODS: Data was collected at baseline, at 12 weeks and at 24 weeks. This short communication presents the results for patients enrolled from Central and Southern Tunisia. RESULTS: A total of 142 patients were enrolled in the study. Four different insulin analogue regimens were used in the study. Study patients had started on or were switched to biphasic insulin aspart (n = 32), insulin detemir (n = 66), insulin aspart (n = 2), basal insulin plus insulin aspart (n = 39) and other insulin combinations (n = 3). At baseline glycaemic control was poor for both insulin naïve (mean HbA1c: 10.5%) and insulin user (mean HbA1c: 9.9%) groups. After 24 weeks of treatment, both groups showed improvement in HbA1c (insulin naïve: -2.4%, insulin users: -1.7%). SADRs including major hypoglycaemic events or episodes did not occur in any of the study patients. CONCLUSION: Starting or switching to insulin analogues was associated with improvement in glycaemic control with a low rate of hypoglycaemia.