Medical management of diabetes after bariatric surgery

Several studies indicate that bariatric surgery frequently leads to resolution or improvement of type 2 diabetes in overweight patients. However, the medical postoperative management requires lifelong counselling, monitoring and nutrient supplements in patients in remission as well as in patients who continue to be diabetic. The aim of such management is to avoid nutritional deficiencies, and to delay diabetes relapse by optimizing the control of risk factors. To this end, diet and pharmacological prescriptions, including vitamin and mineral supplements, are indispensable, despite the fact that specific recommendations, until now, have been lacking for these particular patients.

[Obesity and cancer]

Obesity which is now well recognized as a public health problem increases the risk of developing cancers. Some systematic review and meta-analyses assessed the strength of associations between body mass index and common cancers such as breast, endometrial, colon and adenocarcinoma of oesophagus. The causal mechanisms remain unexplained. However, epidemiological data and animal models have provided some evidence that hormonal alteration linked to obesity, such as hyperinsulinism, high insulin-like growth factor (IGF-1) levels or biodisponibility, low adiponectin serum level and high oestradiol serum level resulting from an enhanced aromatase activity may have mitogenic and antiapoptotic effects. The inflammation associated with visceral adiposity is another factor which promotes cancer. To date, there are no convincing data that weight loss could improve the prognosis of treated neoplasia. However, a regular physical activity and a limited caloric intake are probably safe in healthy subject to prevent cancer and also in cancer survivors.

Increased reverse triiodothyronine is associated with shorter survival in independently-living elderly: the Alsanut study

OBJECTIVE

Increased reverse tritiodothyronine (T(3)) used to be described as a part of euthyroid sick syndrome (ESS). It was demonstrated to be associated with increased mortality in acutely ill patients. It can also be found with low or normal T(3) in non-severely ill subjects but its significance remains unclear.

PATIENTS AND DESIGN

The Alsanut study included a representative sample of 440 independently-living subjects aged 65 or over constituted between January 1988 and September 1989. Past and current medical history and nutritional data were collected at inclusion. Baseline thyroid hormone (TSH, FT(4), FT(3) and rT(3)) serum levels were measured. Life status was determined on 1 December 2005.

RESULTS

Of the 374 elderly subjects included in the final analysis, 52 had abnormal TSH (43 with hyperthyroidism, nine with hypothyroidism) and 80.7% had died by 1 December 2005. There was no statistical difference in survival between subjects according to thyroid function (P=0.54). Of the 322 elderly subjects with normal TSH, mortality rate was 81.1%. ESS was found in 3.4%, whereas 8.1% of the participants displayed elevated rT(3) with normal FT(3). Time to death was strongly related to rT(3) (P<0.0001) and FT(3) (P<0.0001) in a univariate analysis. After adjusting for other confounding variables, rT(3) was the only thyroid hormone associated with shorter survival (P=0.014).

CONCLUSIONS

RT(3) was the only thyroid hormone associated with shorter survival in a representative population of independently-living elderly. In these subjects, isolated elevated rT(3) might be an equivalent of ESS, reflecting declining health.

Hypothyroïdie fruste et grossesse

Pregnancy has an important impact on thyroid homeostasis. The main hormonal criteria of the thyroid function are modified particularly in case of low iodine supply. Subclinical hypothyroidism is defined by a slight elevation of TSH (with a cut-off still under discussion near to 4 mU/l) although serum thyroxine and triiodothyronine levels are within the normal range. Maternal morbidity as well as prenatal morbidity and consequences on the neuropsychological development of the child are fairly well established in subclinical hypothyroidism. However, to date, there are no convincing trials assessing the efficacy levothyroxine in subclinical hypothyroidism all the more when TSH levels are between 3 and 4 mU/l. Therefore routine screening for and treatment of subclinical hypothyroidism during pregnancy are unwarranted.

Comparison of seven serum thyroglobulin assays in the follow-up of papillary and follicular thyroid cancer patients

BACKGROUND

Serum thyroglobulin (Tg) is the marker of differentiated thyroid cancer after initial treatment and TSH stimulation increases its sensitivity for the diagnosis of recurrent disease.

AIM

The goal of the study is to compare the diagnostic values of seven methods for serum Tg measurement for detecting recurrent disease both during L-T4 treatment and after TSH stimulation.

METHODS

Thyroid cancer patients who had no evidence of persistent disease after initial treatment (total thyroidectomy and radioiodine ablation) were studied at 3 months on L-T4 treatment (Tg1) and then at 9-12 months after withdrawal or recombinant human TSH stimulation (Tg2). Sera with anti-Tg antibodies or with an abnormal recovery test result were excluded from Tg analysis with the corresponding assay. The results of serum Tg determination were compared to the clinical status of the patient at the end of follow-up.

RESULTS

Thirty recurrences were detected among 944 patients. A control 131I total body scan had a low sensitivity, a low specificity, and a low clinical impact. Assuming a common cutoff for all Tg assays at 0.9 ng/ml, sensitivity ranged from 19-40% and 68-76% and specificity ranged from 92-97% and 81-91% for Tg 1 and Tg2, respectively. Using assays with a functional sensitivity at 0.2-0.3 ng/ml, sensitivity was 54-63% and specificity was 89% for Tg1. Using the two methods with a lowest functional sensitivity at 0.02 and 0.11 ng/ml resulted in a higher sensitivity for Tg1 (81% and 78%), but at the expense of a loss of specificity (42% and 63%); finally, for these two methods, using an optimized functional sensitivity according to receiver operating characteristic curves at 0.22 and 0.27 ng/ml resulted in a sensitivity at 65% and specificity at 85-87% for Tg1.

CONCLUSION

Using an assay with a lower functional sensitivity may give an earlier indication of the presence of Tg in the serum on L-T4 treatment and may be used to study the trend in serum Tg without performing any TSH stimulation. Serum Tg determination obtained after TSH stimulation still permits a more reliable assessment of cure and patient's reassurance.

Complicated sigmoid diverticulitis

In medical practice, the colonic diverticulitis diagnosis is easy, based especially on a barium enema and an inferior digestive endoscopy, but the diverticulitis complications, especially metastatic infections, raise serious positive and differential diagnosis problems. We present the case of a 51 year old male who comes with hepatomegaly and multiple hepatic formations, in deteriorating clinical condition, context suggestive of secondary metastasis, but after investigation it was demonstrated they were of infectious nature, from a sigmoidian diverticulitic abscess. In this case, the hepatic biopsy was appropriate and it represented an important moment in the management of the patient.

L'hypothyroïdie fruste est-elle un facteur de risque cardiovasculaire ?

OBJECTIVES

Subclinical hypothyroidism defined by the presence of elevated TSH levels but normal free T4 level is a common situation. Its consequences on health are yet on debate and the interest of a precocious treatment remains surrounded by controversy.

KEY POINTS

The relationship between subclinical hypothyroidism and cardiovascular disease has been evaluated by several cross-sectional and longitudinal studies. Subclinical hypothyroidism has direct but subtle effects on the heart function, on the peripheral vascular resistance, and is associated with a mild elevation of LDL-cholesterol levels; all abnormalities may be partly reversed by a thyroxine supplementation. Data of the literature give insufficient evidence as to whether subclinical hypothyroidism is an independent cardiovascular risk factor. However treatment of subjects with TSH levels up or near to 10 mU/l would probably be beneficial in the prevention of cardiovascular disease.

FUTURE PROSPECTS

Based on observational and interventional studies there are some arguments on the benefit of euthyroidism restoration only in patients with TSH levels superior to 10 mU/l.

Étude observationnelle KIMS du traitement par GH des patients adultes ayant un déficit somatotrope: analyse à 12 mois des données françaises

KIMS study is an international, observational study initiated in 1994 in which France has been involved since 2003. Its aim is to collect on a widespread basis long-term data from GH-deficient adults treated or not treated with growth hormone in daily practice. Among 330 patients already enrolled by 128 centers in France at the data lock point for this first interim analysis, 122 patients were followed up for at least 12 months and their results are presented herein. After one year of treatment, IGF-1 level adjusted for age and sex was normalized for 77% of patients naive of GH-treatment, 71% of semi-naive patients and 85% of non naive patients. Lean mass increase was 5.1% and fat mass decrease 5.7%. Quality of life assessed through QoL-AGHDA questionnaire was improved with a median score decrease from 10 to 6. These are the first results available from French patients and suggest that growth hormone is an appropriate indication for adults with severe GH deficiency.

[Impact of systemic disease on the pituitary gland]

Systemic diseases located in hypothalamo-pituitary region can slowly induce pituitary deficiency, diabetes insipidus and morphological abnormalities. The aim of this study is to review recent clinical data about diagnosis of these rare diseases, with a focus on granulomatous diseases: histiocytosis and sarcoidosis. Recent clinical studies on histiocytosis have improved our knowledge about endocrine expression of the disease in children and in adults as well. Diabetes insipidus is the most frequent condition, described mainly in children. GH deficiency is the most frequent pituitary deficit in children and adult patients. During neurosarcoidosis, diabetes insipidus is the most frequent condition and gonadotropic deficiency is the most frequent deficit but GH has not been systematically studied. MRI allows visualisation of some lesions and is very useful to follow the disease course. Diagnosis of these diseases is made by clinical evaluation of all the sites and by pathological analysis of biopsies of peripheral lesions. While pituitary hormone replacement therapy does not seem to raise specific problems in these diseases, etiological treatments are not yet available and indications for antimitotic or immunomodulatory treatment are sometimes discussed.

[Pituitary metastases from lung cancer. Five cases]

Pituitary metastases are rare and generally asymptomatic. We studied 5 patients with pituitary metastases from lung cancer, illustrating the different clinical features. These metastases were in these cases symptomatic with the manifestation being diabetes insipidus or visual field defect. Histological subtypes from our five patients were as well small cell or non small cell lung cancer. After diagnosis of pituitary metastasis, prognosis seems to be linked to the histological subtype and the stage of lung cancer, rather than to the presence of such metastases.

Pseudosyndrome de Gougerot-Sjögren et boulimie

INTRODUCTION

Bilateral parotid enlargement are presenting features of some metabolic and systemic disease but also of chronic emesis.

CASE RECORD

A 24-year old woman consulted during three years many physicians asking for the treatment of a painless parotid swelling confusing with a Sjogren's syndrome. After an initial denial, the weight history, alteration of tooth wear and hypokaliemia conducted to admit a self inducing vomiting with bulimia nervosa.

CONCLUSION

Gender, young age, weight history, tooth alteration and electrolytic disorders are the main diagnostic tool of this dissimulated etiology of parotid swelling.

Circulating procoagulant microparticles in obesity

AIM

Obesity is a risk factor for cardiovascular diseases and venous thromboembolism. Circulating procoagulant microparticles (MP) have been described in various clinical situations associated with thrombosis and in diabetic patients. The aim of this preliminary study was to evaluate the presence of MP in obese patients without any other vascular risk factor in particular diabetes.

METHODS

Fifty-eight obese women <50 year-old without other cardiovascular risk factors were recruited from a single out-patient nutrition clinic. They were compared to 45 age-matched healthy normal weight controls. Main outcome was MP levels in patients and controls. Relationships between MP concentrations and parameters reflecting insulin resistance in patients were also studied.

RESULTS

Obese patients were 33.3 +/- 1.2 years old and had a mean BMI of 42.4 +/- 0.9 kg/m2. There vas a greater proportion of smokers in the obese group (34.5 vs 15.6%). Mean MP levels were markedly higher in obese patients compared to controls (10.6 +/- 0.5 vs 3.2 +/- 0.3 nMPSeq, P < 0.001). There was no difference in MP concentrations between smokers and non smokers. In the obese group, there was a negative correlation between MP and BMI (r = -0.265, P < 0.05) but no relationship could be established between MP concentrations and markers of insulin resistance.

CONCLUSION

This increase in circulating MP levels reflects cell activation and could account for the increased risk of thrombotic complications in obesity. Further studies are ongoing to explore the relationships between MP levels and coagulation markers and to assess the effect of weight reduction.

ICAPS: a multilevel program to improve physical activity in adolescents

OBJECTIVES

ICAPS (Intervention Centred on Adolescents' Physical activity and Sedentary behaviour) is aimed at preventing excessive weight gain and cardiovascular risk in adolescents by promoting physical activity (PA) with an emphasis on recreational and daily-life PA, with a lifelong perspective.

DESIGN

Randomized study designed to last for four years. Study cohort constituted of 954 first-level students (91% of eligible pupils), aged 11.7 +/- 0.6 y (mean +/- SD) from four pairs of schools randomly selected in eastern France, after sociogeographical stratification. In each pair, intervention status was randomised at school-level. The program, not limited to school settings, involves multiple partners with three objectives: 1) changing attitudes through debates and access to attractive activities during breaks and after-school hours, 2) encouraging social support, 3) providing environmental conditions that enable PA. Adapted times and places, open participation, emphasis on fun, meeting with others and absence of competitive aspects are used to reduce usual barriers to PA. Accessibility and safety are permanent concerns.

RESULTS

Prevalence of overweight was 23.7%. High participation rates were attained (50% participated in at least one weekly activity). At six-month, the proportion of intervention adolescents not performing supervised PA out of academic PA was reduced by half (36% to 17% vs 42% to 42% in controls P < 10-4); the proportion of those spending > 3 h/day in sedentary occupations decreased (34% to 28% vs 27% to 36%; P < 10-4).

CONCLUSION

These data demonstrate the feasibility of implementing a multilevel PA intervention program in adolescents. Six-month results document increased PA and decreased sedentary behaviour.

[Cobalamin deficiencies in adults: update of etiologies, clinical manifestations and treatment]

PURPOSE

Update of the adult cobalamin deficiencies.

CURRENT KNOWLEDGE AND KEY POINTS

More precise definitions establish the true cobalamin deficiencies and determine their real epidemiology. The current clinical data suggest the concept of food-cobalamin malabsorption as the leading etiology of cobalamin deficiency. The new features of cobalamin deficiency include neurological, gynecological and vascular manifestations. Current treatment modalities include nasal, sublingual and oral cobalamin administration.

PROSPECTS AND PROJECTS

Studies are in the way to establish the relevance of the new clinical manifestations and to validate the usefulness of oral cobalamin therapy.

[Cellular mechanisms of thyroid hormone action]

KEY POINTS

Thyroid hormones affect cardiac myocytes as well as the smooth muscle and endothelial cells of the vascular wall. Free 3,53'-L-triiodothyronine (FT3) and its specific nuclear receptor modulate the transcription of various proteins, principally those involved in the myocyte contractile apparatus (myosin heavy chains), and the regulation of intracellular calcium flux (sarcoplasmic reticulum Ca2+ATPase). Thyroid hormones also have non-genomic effects that work rapidly, complement the effects described above, and are related to alterations in the properties of many channels and membrane receptors, especially in the sinoatrial mode. Thyroid hormones also affect the smooth muscle and endothelial cells of the vascular walls and reduce systemic vascular resistance. These effects on cardiac and vascular cells globally explain the cardiac manifestations (especially the inotropic and chronotropic effects) observed during dysthyroidism, particularly in hyperthyroidism where they are often in the forefront (positive inotropic and chronotropic effects).

[Cardiac consequences of subclinical dysthyroidism. Experimental, clinical, and epidemiologic data]

KEY POINTS

Although the cardiovascular consequences of clinical or "overt" dysthyroidism are well known and treatment relatively well established, subclinical dysthyroidism remains a controversial topic, both regarding its cardiovascular effects and the best methods for its management. Subclinical hyperthyroidism is frequent among the elderly, usually associated with multinodular goiter. Although several epidemiologic studies have demonstrated that subclinical hyperthyroidism is associated with an increased risk of atrial fibrillation and high cardiovascular mortality, solid practical data on which management can be based are not currently available. The risks related to subclinical hypothyroidism appear essentially vascular but a conclusive assessment must await further epidemiologic surveys.

Répercussions cardiaques des dysthyroïdies avérées

KEY POINTS

Thyroid hormones affect the vascular system, including the diastolic and systolic functioning of the heart. Resting heart rate increases early in hyperthyroidism (cardiac contractility expands due to improved ventricular loading and decreased systemic vascular resistance). Paradoxically, these hemodynamic alterations progressively reduce cardiac performance on effort (changes in diastolic, then systolic functioning) and finally at rest (modification in ventricular loading following tachycardia or atrial fibrillation), especially in cases of underlying heart disease (in the elderly). Hypothyroidism has an inverse hemodynamic effect and is less noisy, usually limited to relative bradycardia. The morbidity and mortality associated with hypothyroidism are apparently related to the atherogenic and prothrombotic vascular modifications that follow thyroid hormone deficiency, whereas heart failure and particularly atrial fibrillation and its thromboembolic complications are the primary consequences of hyperthyroidism. In both cases, return to normal thyroid levels corrects the cardiac abnormalities caused by the dysthyroidism. Dysthyroidism (hypo- or hyperthyroidism) occurs in 10 to 20% of the patients treated with amiodarone for arrhythmia. Because of its potential seriousness, some clinical or laboratory tests are necessary before initiating treatment, and specific clinical surveillance should be scheduled, including laboratory tests.

Physical activity is inversely related to waist circumference in 12-y-old French adolescents

BACKGROUND AND OBJECTIVE

Waist circumference (W) has been shown to be a good predictor of cardiovascular risk. The aim of this study was to investigate whether physical activity (PA) is related to W in adolescents as previously shown in adults.

DESIGN AND SUBJECTS

Cross-sectional population-based survey of 2,714 12-y-old adolescents from the eastern part of France.

MEASUREMENTS

Body mass index (BMI) and W were measured. Structured PA, active commuting to and from school and sedentary activities (SED), for example television viewing, computer/video games and reading and different potential confounders (dietary habits, parental overweight, family annual income tax and educational level) were assessed by a questionnaire.

RESULTS

The adolescents had a mean BMI of 19.0+/-3.4 kg/m2, and 20.2% of them were overweight, with no gender difference. Boys had a greater W than girls (67.6+/-9.1 vs 65.7+/-8.9 cm, P<0.0001). In all, 42% of the girls and 25% of the boys did not practice any structured PA outside school and less than 40% of the adolescents commuted actively to school more than 20 min/day. About one-third of the adolescents devoted more than 2 h/day to SED. In univariate analyses, BMI was negatively associated with structured PA but significantly only for girls (P<0.01) and positively associated with SED for both genders (P<0.0001 for girls, P<0.01 for boys). W was negatively associated with structured PA and positively associated with SED both in girls (P<0.0001 and P=0.03, respectively) and boys (P<0.01 and P=0.08, respectively). Multiple general linear models show that SED is associated with BMI, independently of structured PA, in both genders. On the other hand, structured PA was inversely associated with W, independently of SED. The inverse relation between structured PA and W persisted after additional adjustment on BMI, with a greater effect of PA for the adolescents with higher BMI.

CONCLUSIONS

In 12-y-old adolescents, structured PA is inversely associated with W, an indicator of total adiposity but also more specifically of abdominal fat. This suggests that PA may have a beneficial effect on youth metabolic and cardiovascular risks, in particular in the presence of overweight..

Hyperammonaemic encephalopathy induced by a commercial very-low-energy diet in a neglected ornithine-carbamoyltransferase-deficient woman

This case report describes a 31-year-old woman with a neglected ornithine carbamoyltransferase deficiency, admitted for a hyperammonaemic encephalopathy induced by a commercial very low-energy diet. To our knowledge, this is the first reported case and it underlines the potential risk of such a diet in patients with undiagnosed or neglected ornithine carbamoyltransferase deficiency.

Parent-child physical activity relationships in 12-year old French students do not depend on family socioeconomic status

OBJECTIVES

Regular physical activity (PA) in young needs to be promoted to prevent obesity and subsequent diabetes. Influences of parental PA on adolescents' activity level have been studied with discordant results and the effect of socioeconomic status (SES) on these relationships is not clarified.

METHODS

Cross-sectional population-based survey of about 3000 12-year old French students and their parents. Familial associations were assessed with logistic regression models taking into account SES and children's and parents' corpulence. Sport involvement and sedentary behaviors were assessed by standardized questionnaires filled out separately by children and parents, the latter also reporting their educational data and family income tax.

RESULTS

Participation in structured PA outside school was higher for boys (74%) than for girls (58%, p<10-5) and a high sedentary behavior (watching television, playing computer/video games and reading > or =2h/day) was observed in one-third of the sample, both in boys and in girls. Children were more likely to participate in structured PA outside school when both parents practiced sport as compared to neither parent practicing it, with an odd ratio OR (95%CI) of 1.97 (1.4-2.8) for boys and 1.56 (1.2-2.1) for girls. Familial associations of inactivity were significant for boys only. A greater percentage of adolescents had a high level of sedentary behavior when both parents versus no parents watched television > 2h/day (OR 1.95 (1.52.6)). Parent-child physical activity relationships were not modified by the family SES or the children's or parents' weight status.

CONCLUSION

Parental involvement in sport is an important correlate of a young adolescent's participation in structured PA outside school, whatever the family SES or corpulence of the family members.

[Auto-immune-like disease post-bone marrow transplantation]

INTRODUCTION

Bone marrow transplantation (BMT) is based on destruction of the patient's bone marrow with rescue of haematopoietic stem cells from a donor. Chronic graft-vs-host disease (GVH) is the major complication post-BMT and mimics some autoimmune diseases, such as scleroderma, sicca syndrome, primary biliary cirrhosis and an increased prevalence of various autoantibodies. Other autoimmune-like manifestations have been reported as case reports or short series. The most common are myasthenia gravis, polymyositis, autoimmune cytopenias and Graves' disease or autoimmune hypothyroidism.

CURRENT KNOWLEDGE AND KEY POINTS

These diseases occur mainly in association with chronic GVH. The pathophysiology of chronic GVH and other autoimmune-like diseases post-BMT remains poorly understood. Different mechanisms have been postulated. Most of the autoimmune events (either chronic GVH or more specific diseases) seem to be related to a poor or inadequate immunologic recovery post-BMT with an imbalance between autoregulatory and autoreactive lymphocytes. Microchimerism and molecular mimicry have been recently evocated. A minority of cases (autoimmune thyroid disorders) is attributed to the direct transfer of autoreactive cells from donor to patient (adoptive immunity).

FUTURE PERSPECTIVES

Despite physiopathologic uncertainty, these autoimmune-like disorders post-BMT are an interesting model for primary autoimmune diseases.

Sympathovagal response to orthostatism in overt and in subclinical hyperthyroidism

Heart rate variability (HRV) is a measure of the physiological variation of R-R intervals, reflecting the sympathovagal balance. In both overt and subclinical hyperthyroidism, a relative increase in sympathetic activity has been demonstrated, mainly due to a decrease in vagal activity. The modifications of HRV during orthostatism in normal subjects resemble those seen in hyperthyroidism. We have studied the response of 19 patients with overt hyperthyroidism and 12 with subclinical hyperthyroidism during orthostatism using HRV and compared the results to those of 32 healthy controls. In the three groups, the R-R intervals decreased in the same proportion after orthostatism. The low frequency power (LF)/[LF + high frequency power (HF)] ratio, which reflects the sympathetic tone, also increased in the same proportion in the three groups. However, the mechanisms of the modulation of the sympathovagal balance during orthostatism were different among the three groups. In controls, the relative increase of sympathetic tone after orthostatism was due principally to a decrease in vagal tone (reflected by decreased power in the HF band), while in overt hyperthyroidism, where the power in the HF band was already minimal in the lying position, there was a clear increase in the LF band power during orthostatism. The results were intermediate in the subclinical hyperthyroidism group, reflecting a continuum of effects of the thyroid hormone excess on the autonomic nervous system. Our study shows that despite an apparent normal cardiovascular adaptation to orthostatism in hyperthyroidism, the modulation of the autonomic nervous system is profoundly modified.

Retrospective study of laparascopic adjustable silicone gastric banding for the treatment of morbid obesity: results and complications in 127 patients

OBJECTIVES

Laparoscopic gastric banding is currently the most popular surgical technique for morbId obesity. This wIdespread use of surgery has been evaluated by a number of clinical studies, particularly on weight change.

METHODS

In a retrospective study of 127 obese patients operated between 1996 and 2000, data were collected for weight change, medical and surgical complications.

RESULTS

Of 127 patients, failures of gastric banding were noted during 2 surgical operations. The average follow-up period was 33 +/- 20 Months. Average weight loss in all patients was 19.9 +/- 5.3 kg (15.3 +/- 4.2%). No difference in weight loss was observed between diabetic and non-diabetic patients. During the follow-up, data were collected on 53 complications (42.4% of all gastric banding operations). 3 main types of complication were found: access port related complications (22.6% of the total), band slippage (20.7% of the total) and tubing related complications (16.9% of the total). No prognostic factor for these complications could be Identified from multivariate analysis.

CONCLUSIONS

Our results are very similar to those of other weight evolution studies. We found that there was a significant incIdence of surgical and medical complications during the follow-up because of the meticulous way all complications were recorded, even the most insignificant. This morbIdity must be borne in mind before surgery is performed.

[Sub-clinical hypothyroidism, towards the end of a controversy?]

DEFINING THE PROBLEM: Sub-clinical hypothyroidism, defined as a moderate and isolated increase in TSH levels, is a common syndrome and is the first phase of a progressive disease. However its treatment remains controversial. Some anamnestic, clinical and biological (anti-thyroperoxidase antibodies) parameters contribute in identifying the patients most likely to progress towards overt hypothyroidism. WHAT CAN BE EXPECTED OF TREATMENT? Several clinical studies have described cardiovascular, neuromuscular and lipid disorders in these patients, but administration of levothyroxine has provided varying results and does not enable the distinction between a pharmacological-like intrinsic effect of the thyroid hormone and the true benefits imputable to the correction of TSH, in the absence of any large interventional study. More studies are required to better identify the patients who will benefit most from hormone replacement.

[Smoking and the thyroid]

The effects of smoking on the thyroid gland have been studied for years. The consequences of smoking on thyroid function and size are however still controversial. It is accepted that an increase in serum thyiocyanate, a potent inhibitor of iodine transport, may contribute to the development of thyroid dysfunction, particularly in geographical areas with borderline iodine deficiency. In the general population, smoking is associated with normal thyroid hormone levels, with a tendency to lower TSH levels and enlargement of thyroid size. There is an increased risk of developing over thyroid disease. The relationship between smoking and relapse of Graves' disease and the incidence and severity of Graves' ophthalmopathy are constantly reported. Smoking also has a potent nodular goitrigenic effect in low iodine areas. Despite the fact that smoking decrease both thyroid secretion and thyroid hormone action, hypothyroidism does not appear to be more frequent. Smoking does however increase the metabolic effects of hypothyroidism. Active and passive smoking have proven deleterious effects on the fetal thyroid. Paradoxically, there is evidence of reduced risk for thyroid cancer in smokers.

[Thyroxine (T4) and tri-iodothyronine (T3) determinations: techniques and value in the assessment of thyroid function]

Hormonal production of the thyroid gland is constituted of thyroxine or T4 (80%) and triiodothyronine or T3 (20%). In the circulation, whole T4 originates from thyroid secretion but most of T3 (80%) is produced extrathyroidally from T4 deiodination. Conversion of T4 to T3 may be influenced by various conditions and circulating T3 is a less reliable reflection of thyroid hormone production than T4. In serum most of T4 and T3 is bound to binding proteins and only 0.02% of T4 and 0.3% of T3 is free. Because of their higher diagnostic performance, free T4 (FT4) and free T3 (FT3) measurements have superseded total (free + bound) hormone determination. Total hormone measurements remain useful for research studies or in case of severe hyperthyroidism. Equilibrium dialysis/RIA is considered as the reference method for free hormone measurements. Routine clinical laboratories use automated direct two-step or one-step immunoassays with a high molecular weight ligand or labelled antibody. Free hormone measurement remains technically demanding, especially in sera from severe non-thyroid ill patients with low serum thyroxine binding capacity. Interference from anti-thyroid hormone antibodies and familial dysalbuminemic hyperthyroxinemia depends on the assay method, but is now less marked and less frequently detected. To be able to correctly interpret the results of an assay, it is necessary to assess its performance in biologically and clinically well-characterised serum samples. FT4, and FT3 measurements, if FT4 is normal and hyperthyroidism suspected, are used to confirm and assess the level of hypo and hyperthyroidism (overt or subclinical). When the thyroidal status is unstable (first months of a thyroid treatment, altered L-T4 dose, subacute thyroiditis) or when the hypothalamic-pituitary function is disturbed (central hypothyroidism), TSH determination is diagnostically misleading and only free hormone measurements are reliable for thyroid function assessment.

Efficacy of short-term oral cobalamin therapy for the treatment of cobalamin deficiencies related to food-cobalamin malabsorption: a study of 30 patients

BACKGROUND

It has been suggested that oral cobalamin (vitamin (B12)) therapy may be an effective therapy for treating cobalamin deficiencies related to food-cobalamin malabsorption. However, the duration of this treatment was not determined.

PATIENTS AND METHOD

In an open-label, nonplacebo study, we studied 30 patients with established cobalamin deficiency related to food-cobalamin malabsorption, who received between 250 and 1000 microg of oral crystalline cyanocobalamin per day for at least 1 month.

ENDPOINTS

Blood counts, serum cobalamin and homocysteine levels were determined at baseline and during the first month of treatment.

RESULTS

During the first month of treatment, 87% of the patients normalized their serum cobalamin levels; 100% increased their serum cobalamin levels (mean increase, +167 pg/dl; P < 0.001 compared with baseline); 100% had evidence of medullary regeneration; 100% corrected their initial macrocytosis; and 54% corrected their anemia. All patients had increased hemoglobin levels (mean increase, +0.6 g/dl) and reticulocyte counts (mean increase, +35 x 10(6)/l) and decreased erythrocyte cell volume (mean decrease, 3 fl; all P < 0.05).

CONCLUSION

Our findings suggest that crystalline cyanocobalamin, 250-1000 microg/day, given orally for 1 month, may be an effective treatment for cobalamin deficiencies not related to pernicious anemia.

[Vitamin B12 deficiency with normal Schilling test or non-dissociation of vitamin B12 and its carrier proteins in elderly patients. A study of 60 patients]

PURPOSE

Approximately 15% of people over 60 years old have a cobalamin (Cbl) deficiency in relation with a food-cobalamin malabsorption (FCM). But to date, only case reports or small series have been reported. The aim of this study was to describe the clinical characteristics of the FCM in old subjects.

METHODS

Sixty patients, at least 65 years old, presenting a Cbl deficiency related to FCM, were extracted from a cohort study of the Hôpitaux universitaires de Strasbourg, France (n = 169). All these patients had an established diagnosis of Cbl deficiency and met the Carmel's criteria of FCM. Their clinical data were retrospectively analysed.

RESULTS

The median age of the 60 patients was 75 years and the female/male ratio was 2.3. The principal clinical symptoms were peripheral neuropathy (35%), confusion and dementia (30%) and anemia-related manifestations such as asthenia and edemas of the legs (20%). Average hemoglobin was 10.7 +/- 2.5 g/dl and average mean erythrocyte cell volume was 95.5 +/- 13.8 fl. There was an anemia, a leucopenia, a thrombocytopenia and a pancytopenia in respectively 27%, 18%, 15% and 8% of the cases. Average serum vitamin B(12) and homocystein levels were with 138 +/- 42 pg/ml and 22.5 +/- 15.2 micro mol/l. No patient had anti-intrinsic factor antibody and the Schilling's test was normal in all patients. Main disorders associated with FCM were atrophic gastritis (59%), long-term metformin or antiacid intake (17%), chronic alcohol intake (8%) and idiopathic FCM (n = 10). Sixteen patients have been successfully treated with oral crystalline cyanocobalamin (500 +/- 280 micro g/d).

CONCLUSIONS

This study shows that: firstly, the Cbl deficiency related to FCM may be responsible of severe neurological and hematologic manifestations in approximately 20% of the elderly patients; secondly, the disorders associated with the FCM are multiple in old age, with mainly atrophic gastritis; and thirdly, in clinical practice, oral cyanoCbl treatment may be successful.

Prevalence and sociodemographic determinants of overweight in young French adolescents

BACKGROUND

The prevalence of overweight in adults and in children is increasing in most industrialised countries. Our purpose is to estimate the prevalence of overweight and obesity in a population of 12-year-old French adolescents and to analyse its association with different sociodemographic factors.

METHODS

A cross-sectional study was conducted in 2001 on a representative sample of sixth-grade adolescents (mean age 12.1 +/- 0.6 years) living in the Department of the Bas-Rhin (Eastern part of France). Height and weight were measured in 4326 adolescents. Overweight and obesity were defined as recommended by the International Obesity Task Force. Sociodemographic data were obtained for 3436 adolescents.

RESULTS

The prevalence of overweight was 22.7% (17.5% of moderate overweight and 5.2% of obesity) and it was not different by gender or by size of the commune of residence. Overweight was more frequent in low economic zones (p < 10(-4) in girls, p < 10(-2) in boys) and in public schools than in private schools (p < 10(-3) in girls). The prevalence of overweight was inversely associated with family income tax (p < 10(-3) in girls, p = 0.012 in boys), mother's (p = 10(-4) in girls, p = 10(-3) in boys) and father's (p = 0.001 in girls, p = 0.004 in boys) educational level. Multiple logistic regression analysis indicated an independent association of being overweight with low family income tax (p = 0.2195) and poor mother's educational level (p = 0.0193).

CONCLUSIONS

This study indicates that, as in other industrialised countries, much overweight and obesity are present in 12-year-old French adolescents. It suggests the existence of an influence of socio-economic factors with a predominant effect of the mother's educational level rather than the financial resources.

[Gastroplasty: complications and their prevention]

Bariatric surgery is now frequently proposed for the treatment of morbid or complicated obesity since the introduction of minimally invasive laparoscopic anti-obesity operations such as the adjustable silicone gastric binding gastroplasty. However this reversible procedure in not always as safe as presumed and the results in weight loss may be sometimes disappointing. Side effects are common and early or late complications occured in more than 20% out of the patients. They are favoured by post operative eating disorders. Nutritional consequences are probably underestimated and are not limited to uncomfortable digestive symptoms. Some deficiencies in micronutriments have been described. The worsening of previous eating disorders or psychosocial abnormalities are not seldom. Gastroplasty is not an harmless procedure. A good selection in patients, a regular follow up, nutritional advices and psychosocial management by a multidisciplinar team are required to reduce complications after gastroplasty.

[Development and long-term prognosis of unexplained persistent inflammatory biologic syndromes]

PURPOSE

Unexplained inflammatory syndrome is a frequent and worrying condition in Internal Medicine. However, the long-term clinical outcome of these patients cannot be inferred from the literature. The aim of this study is to describe the long-term follow-up and the prognosis of a group of patients hospitalised for an inflammatory syndrome and discharged without causal diagnosis.

METHODS

This retrospective study was carried out on 46 patients, 15 men and 31 women, aged 21 to 90 years, hospitalised between 1992 and 1999. Data concerning the hospital stay were obtained from the patients' medical record. Follow-up was performed by consulting the treating physician.

RESULTS

The prognosis of these patients is fairly good. In one third of the cases, the inflammatory syndrome resolved spontaneously (n = 13). In the second third, a definite diagnosis was established after discharge (n = 14) and consisted mainly of chronic inflammatory diseases (n = 9), cured with a specific treatment. In the remaining third (n = 12), the inflammatory syndrome persisted, in clinically asymptomatic patients.

CONCLUSION

These results suggest that the persistence of an inflammatory syndrome is not a poor prognostic factor. Thus we propose for patients discharged with an undiagnosed persistent inflammatory syndrome despite thorough investigations, a simple clinical and biological follow-up instead of repeated etiological investigations.

Changes in physical performance in elderly Europeans. SENECA 1993 - 1999

OBJECTIVE

To assess longitudinal changes in subjective and objective measures of physical performance in elderly Europeans.

DESIGN

Longitudinal study including SENECA measurements 1993-1999.

SETTING

Data were collected in 9 'traditional' European towns.

SUBJECTS AND METHODS

In total 444 men and women, born 1913-1918 participated both in the follow-up survey in 1993 and in the finale in 1999. Changes in Activities of Daily Living (ADL), the 7 item Physical Performance Test (PPT) and in the ability to perform the chair stand and the tandem test were measured.

RESULTS

ADL and PPT did not change significantly between the 2 surveys, while participants needed more time to perform the chair stand (p<0.02) and their balance declined according to the tandem test (p< 0.01). Men were significantly better than women, in all measures of physical performance. However, the decline in functioning was of the same magnitude. All tests showed significant variation between centres in physical function. Significant cross cultural variation was found for changes in the capacity to perform the objective tests. Tests of distributions showed good association between the self reported and objective measures of physical performance. Rather than assessing the same task in several ways, the measures may reflect different levels of disability, and as such be important end point measures.

CONCLUSIONS

Both ADL and objective tests of simple functions applied well in the SENECA population. Physical performance declines with age. Across European towns variation in physical performance was identified.

Health related quality of life and physical performance. SENECA 1999

This paper describes health related quality of life in 81-85 year old participants of the SENECA study and relates outcome to health and physical performance.

DESIGN

SENECA is a mixed-longitudinal study in birth-cohorts, 1913-1918, with baseline measurements in 1988/1989 repeated in 1993 and 1999. Nine towns collected data in 1999. The study population consisted of 445 survivors.

METHODS

Health related quality of Life was measured by The Nottingham Health Profile (NHP). Percentages of answers (yes/no) to 38 items were used for scoring different dimensions. Self-perceived health was measured by a global question with five answer categories and chronic diseases as presence or absence of any chronic reported disease. For functional ability, a standardised Activity of Daily Living (ADL) questionnaire was used with 16 questions on a 4-point scale. Functional limitations were measured by a sum-score of objective simple functions tests (PPT).

RESULTS

Average scores in the different sections were: Energy:46, pain:55, emotional reactions:58, sleep:64, social integration:47 and physical mobility:70 11% had no problems in any of the sections. All health and physical performance measures were significantly associated with, not only physical mobility, but also affective and social components of quality of life, age 81-85.

CONCLUSION

The Nottingham Health Profile was a useful instrument to measure health related quality of life in physical, affective and social dimensions across birth cohorts, gender and culturally different towns in Europe. The answers apparently mirrored the subjective disadvantage of impairment-related functional limitations and may therefore be used as end point for further analyses of SENECA data.

Ten-year trends of dietary intake in a middle-aged French population: relationship with educational level

OBJECTIVE

To compare dietary intakes at a 10 y interval of a population aged 35-64 living in France. Trends in nutrient intake and food consumption were examined with a special emphasis on the relationships between educational level and dietary behaviour.

DESIGN

Two independent surveys conducted in 1985-1987 (S1) and 1995-1997 (S2) in the framework of the WHO MONICA project. Dietary intake was assessed with a 3-day record method and a food frequency questionnaire. The samples analysed included 416 men and 446 women for S1, 393 men and 409 women for S2.

RESULTS

A significant improvement of the quality of fat intake was observed between S1 and S2, independently of educational level, with an increase of the age adjusted P/S ratio from 0.42 to 0.50 in men (P=10(-4)) and from 0.41 to 0.50 in women (P=10(-4)), whereas the daily cholesterol intake dropped from 552.0 to 466.9 mg and from 447.2 to 384.6 mg in men and women, respectively (P=10(-4)). These variations were associated with a decrease in the consumption of high-fat foods and an increase in that of low-fat products (poultry, low-fat dairy foods, fish) in all educational classes. By contrast, the consumption of fruit and vegetables, which was highly associated with educational level, varied little over time.

CONCLUSIONS

Our results indicate slight improvement in fat quality, independently of educational level, while fruit and vegetable intake, which appeared more dependent on educational level, was only poorly modified over the 10 y interval.

[DHEA: an unknown star]

PURPOSE

To clarify the physiological function of dehydroepiandrosterone (DHEA), the most abundant steroid in human plasma, which remains poorly understood. To analyse the beneficial effects of a supplementation in order to alleviate its decrease in ageing and improve well-being.

CURRENT KNOWLEDGE AND KEY POINTS

DHEA (and its sulfate) acts on peripheral tissues as an androgenic and estrogenic precursor. It is also considered as a neurosteroid. DHEA administration in several pathological animal models is promising, especially in metabolic diseases such as obesity and insulin resistance. It appears like a factor of immunomodulation and facilitates cognitive acquisition. In humans there is little evidence that DHEA may be useful in characterized pathologies apart from adrenal insufficiency. An interesting effect was also noted in severe systemic lupus erythematosus. The effects on cognitive and neuropsychiatric diseases such as midlife dysthymia are not yet convincing. Prospective studies of supplementation versus placebo indicate inconstant improvement in well-being in the post-menopausal state. DHEA is not a panacea against ageing despite there being a well-established aging-related decrease of DHEA. Contrary to some assertions there are no proven relations between cardiovascular or cancer risk.

FUTURE PROSPECTS AND PROJECTS

Until now adrenal insufficiency has been the only well-documented indication of an oral DHEA supplementation. However, DHEA may be a good way for androgen supplementation in menopausal men. Further investigations are needed to better know the anti-inflammatory and immunomodulation properties of DHEA. At the least, prospective studies on large populations are necessary to assess the true benefits and dangers of DHEA in prevention of ageing.

[Hungry bone syndrome after surgical treatment of severe primary hyperparathyroidism: about 3 cases]

Persistant hypocalcemia occurring after surgical treatment of severe primary hyperparathyroidism may be due to transient or permanent hypoparathyroidism but also to a bone disease. We report three cases of hypocalcemia after surgery of large parathyroid adenoma or hyperplasia in women. Plasma calcium, phosphate and PTH levels are in accordance with Hungry Bone Syndrome (HBS). HBS is related to both excessive bone demineralization and turn over. It is a major importance to distinguish HBS from surgical hypoparathyroidism in order to start early the appropriate treatment given for a long period.

[Hormonal perturbations in fibromyalgia]

Fibromyalgia is a syndrome characterized by chronic musculoskeletal pain and fatigue without biological detectable disturbances. The mechanisms of this disease are unknown. It has been postulated that it can be the consequence of a chronic stress mediated mainly through the hypothalamo-pituitary-adrenal axis and the sympathetic nervous system. These fields have been extensively studied. Results were scattered and non convincing. A reduction of growth hormone and IGF-1 levels described in a third of patients has led to a double blind random clinical trial with biogenetic growth hormone. Results were equivocal . Other hormonal systems are grossly normals and circadian rhythms are unaltered. Despite some arguments in favour of a CRH neurons hyperactivity, these results are not able to consolide a particular physiopathological mechanism and to argument for a new therapeutic approach. Many of the abnormalities may be the consequence of psychological disturbances.

[Alcohol and cardiovascular system: mechanisms of the protective effects]

Moderate and regularly alcohol consumption reduces death rate from coronary heart disease and thrombotic stroke. This beneficial correlation observed with several alcoholic beverages seems to be mainly due to an ethanol effect. However the particular role of microconstituants contained in red wine must be considered. The mechanism of the putative protective effect of alcohol intake is mediated through the elevation of HDL cholesterol and through the aintioxydative effect of polyphenolic compounds. In addition, alcohol acts favourably on platelets agregation, fibrinolysis and several other coagulation parameters. Despite these explanations are yet speculative and there is no causal relation between alcohol and reduced coronary death, epidemiological data are consistent with the belief that daily consumption of one or two glasses of an alcoholic beverage has salutary effect on health.

[Influence of age on presentation and prognosis of tuberculosis in internal medicine]

OBJECTIVES

To compare the clinical, biochemical, radiological features and the outcome of elderly and young patients with tuberculosis.

METHODS

Between 1980 and 1997, 83 patients diagnosed as having tuberculosis were treated in two departments of Internal Medicine and Geriatrics. They were divided into 42 young (< 65 years) and 41 elderly (> or = 65 years) patients and differences in presentation between the two groups were analysed.

RESULTS

A past history of tuberculosis was found in 10% of young and in 18% of elderly patients (p = 0.43). Cancer was more often associated with tuberculosis in elderly patients (2% vs 15%, p = 0.09). The sites of disease were similar in both groups with 2/3 of pulmonary infection. Comparison of the presenting symptoms showed no significant difference for weight loss (52% vs 66%, p = 0.31), fever (52% vs 56%, p = 0.90) and cough (33% vs 32%, p = 1). The skin testing was positive for the majority of the young adults (84% vs 58%, p = 0.11). The commonly observed biochemical abnormalities in elderly patients were an increased erythrocyte sedimentation rate (49 vs 69 mm/h: p = 0.03) and lymphocytopenia (1724 vs 1059/microliter, p < 0.01). There was no significant difference in radiographic findings between both groups with miliary tuberculosis in about 10% of patients. During the first three months of treatment, the mortality was especially high (22%) for the elderly patients.

CONCLUSIONS

Comparison of the clinical and radiological features of tuberculosis in internal medicine showed no significant difference in young and elderly patients.