Le diabète,facteur de dénutrition et de carences en micronutriments ?

Depending on the case, diabetes is cause and/or consequence of the nutritional deficit. In every case studied in this article, the nutritional deficit increases the risk of micro- and macrovascular complications. Elderly diabetic patients are more often undernourished than the nondiabetic patients and this undernutrition influences the frequency and the prognosis of the foot ulcers who are more often infected, heal more slowly and lead more often to amputations. Vitamin D, zinc, magnesium and chromium are involved in the regulation of insulin secretion and in the insulin signaling pathway so contributing to influence insulin sensitivity. During type 2 or type 1 diabetes, the circulating rates of these micro nutrients are significantly lower than in the absence of diabetes without there is yet a real deficiency. Vitamin B12 deficiency is also more frequent in diabetic population than in no diabetics and its frequency increases in case of treatment by metformin because of an effect of this one on its absorption. Deficiencies in vitamin D, zinc and magnesium increase the cardiovascular risk of diabetic patients because of their effect on oxidative stress and on the endothelial dysfunction. The circulating rates of these various nutrients are significantly lowered in the case of cardiovascular complications during diabetes. International studies are in favour of association between these deficits and the arisen of microvascular complications with specificity according to the type of deficit and the type of complication. Whatever is the considered deficit, in spite of these epidemiological data, the available interventional studies are insufficient and do not show that to supplement specifically these deficits can modify significantly the evolution and the prognostic of the diabetes.     

Le risque d’incarcération des personnes suivies en psychiatrie. Une étude longitudinale rétrospective dans le département français de l’Oise à partir du Recueil d’informations médicalisé en psychiatrie

IntroductionCompared to the general population, persons with mental disorders are overrepresented in prison. In a study carried out in Picardy (northern France) in 2017, a quarter of those entering prison had had contact with a psychiatric service prior to their incarceration. Since to our knowledge no work on this subject has been published in France, we conducted a retrospective study, the main objective of which was to propose an estimate measure of incarceration likelihood in people with mental disorders.MethodsUsing data from a psychiatric hospital discharge database (Recueil d’informations médicalisé en psychiatrie, RimP), we searched for patients aged 18 and older who had received psychiatric care (except for those who were incarcerated at baseline) at the Oise psychiatric hospital in 2015-2016 and identified those who had also been registered by the psychiatric care tool (DSP) in liaison with the same hospital. As a marker of incarceration, registration was the event to be investigated. Survival analyses (Kaplan-Meier), first simple and then stratified by age, gender, past history, main diagnosis and intensity of care outside of prison were carried out to calculate likelihood of incarceration. A multivariate Cox model was used in order to identify the factors associated with incarceration.ResultsAmong the 25,029 patients monitored in the Oise psychiatric hospital in 2015-2016, 126 had experienced incarceration during the 12 months following their inclusion in the study, i.e. an incarceration probability of 0.45% (95 % confidence interval: 0.37–0.55%). The incarcerated patients were younger (36.6 years in average versus 44.7–P t-test < 0.0001), more often male (96.8% versus 43.7% - P < 0.0001), and had a more frequent history of detention (11.1% versus 0.6% – P  < 0.0001) and psychiatric care (20.6% versus 10.1% – P < 0.0001) than the general population. The probability of incarceration at 12 months for the population followed in the psychiatry unit was 3.2 times higher than the detention rate of the general population in Oise over the same period.ConclusionOur study confirms the pronouncedly high incarceration rate of people with mental disorders. Scheduled to begin in 2020, coding in the RimP of a single nationwide patient identifier for all the procedures and stays described will allow the generalized measurement by means of the proposed indicator throughout France.     

Profils métabolique et clinique avant,pendant et après la période du ramadan chez des Maliens atteints de diabète de type 2

ObjectivesTo document the effects of fasting on metabolic and clinical parameters among Malians with type 2 diabetes during Ramadan in Mali.MethodsThis study was conducted with 25 subjects attending the Centre national de lutte contre le diabète in Bamako. Only those that intended to observe the Ramadan fasting in 2010 were selected. Biological and clinical parameters were measured in 25 participants at three different periods: before Ramadan (T0), during the fourth week of Ramadan (T1) and one month after Ramadan (T2).ResultsCompared to T0, an increase was noted at T1 in fasting blood glucose (P < 0.05) and systolic blood pressure (P < 0.01), although not maintained at T2. Glycosylated haemoglobin was also higher at T2 compared to T0 (P < 0.02). Degradation of glycemic control was more marked among patients who had stopped or reduced their doses of medication at T1 (P < 0.01). Also, a decrease in LDL-cholesterol (P < 0.03), total cholesterol (P < 0.05) and total cholesterol/HDL-cholesterol ratio (P < 0.01) were observed at T1, along with a slight weight loss (P < 0.01). Reductions in weight, levels of LDL-cholesterol and total cholesterol/HDL-cholesterol ratio were maintained at T2.ConclusionsThis study showed an adverse effect of fasting on glycemic control among the participants, likely related to the non-observance of oral medication during Ramadan. However, blood lipids sharply improved during Ramadan, and even after.     

La stéatopathie dysmétabolique ou NASH : faut-il dépister les patients à haut risque atteints de diabète de type 2 ou d’obésité ?

Nonalcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver disease worldwide. It encompasses a spectrum of phenotypes including benign hepatic steatosis (NAFL) and nonalcoholic steatohepatitis (NASH) which is considered as the progressive form with higher risk of progression towards liver fibrosis, cirrhosis or hepatocellular carcinoma. NAFLD remains asymptomatic until end-stage of the disease and is largely underdiagnosed. In the last decades, populations at high risk of progression to advanced fibrosis, such as obese and type 2 diabetic (T2D) patients, have been identified. The presence of advanced fibrosis has been identified as the major determinant of overall and hepatic mortality. Liver biopsy remains the gold standard for the diagnosis of NASH and hepatic fibrosis, however several noninvasive blood-based and imaging-based biomarkers have been developed for the assessment and screening for liver fibrosis. Finally, the lifestyle modification and weight loss intervention improve steatosis, NASH and liver fibrosis, and therapeutic clinical trials for the treatment of NASH are an area of intensive research. This review article will summarize the current evidence supporting the systematic screening for advanced fibrosis in high-risk population such as T2D and obese patients. Several modalities are available for such screening. However, additional studies are needed to determine the optimal strategy for a systematic screening in high risk population and to allow efficient and cost-effectiveness pathway referral in hepatology clinics.     

Mise en place d’un programme de prévention et de prise en charge du diabète en Suisse : le point de vue des patients et des professionnels de la santé

BackgroundA reorganization of healthcare systems is required to meet the challenge of the increasing prevalence of chronic diseases, e.g. diabetes. In North-America and Europe, several countries have thus developed national or regional chronic disease management programs. In Switzerland, such initiatives have only emerged recently. In 2010, the canton of Vaud set up the “Diabetes Cantonal Program”, within the framework of which we conducted a study designed to ascertain the opinions of both diabetic patients and healthcare professionals on the elements that could be integrated into this program, the barriers and facilitators to its development, and the incentives that could motivate these actors to participate.MethodsWe organized eight focus-groups: one with diabetic patients and one with healthcare professionals in the four sanitary areas of the canton of Vaud. The discussions were recorded, transcribed and submitted to a thematic content analysis.ResultsPatients and healthcare professionals were rather in favour of the implementation of a cantonal program, although patients were more cautious concerning its necessity. All participants envisioned a set of elements that could be integrated to this program. They also considered that the program could be developed more easily if it were adapted to patients’ and professionals’ needs and if it used existing structures and professionals. The difficulty to motivate both patients and professionals to participate was mentioned as a barrier to the development of this program however. Quality or financial incentives could therefore be created to overcome this potential problem.ConclusionThe identification of the elements to consider, barriers, facilitators and incentives to participate to a chronic disease management program, obtained by exploring the opinions of patients and healthcare professionals, should favour its further development and implementation.