I. Banu

A large proportion of prediabetes and diabetes goes undiagnosed when only fasting plasma glucose and/or HbA1c are measured in overweight or obese patients

AIMS The purposes of the study were to determine the prevalence of unrecognized dysglycaemia in overweight (body mass index [BMI] 25-29.9 kg/m(2)) and obese (BMI ≥30 kg/m(2)) patients, to assess the extent to which measures of fasting plasma glucose (FPG) and/or HbA(1c), compared with oral glucose tolerance tests (OGTTs), misdiagnose dysglycaemia, and to determine the factors associated with an isolated abnormal post-OGTT glucose value. METHODS OGTT was performed and HbA(1c) was measured in 1283 inpatients with BMI scores ≥ 25 kg/m(2) and no history of dysglycaemia. RESULTS Prediabetes was found in 257 (20.0%) subjects (197 with impaired glucose tolerance, 29 with impaired fasting glucose, 31 with both) and diabetes in 77 (6.0%), including 22 with FPG ≥ 7 mmol/L (WHO definition). The sensitivity of FPG >6 mmol/L, FPG >5.5 mmol/L, HbA(1c) ≥ 6% and the recommendations of the French National Agency of Accreditation and Evaluation in Health Care (ANAES) to identify patients with abnormal OGTTs was 29.9, 41.3, 36.8 and 15.6%, respectively. The factors that were independently associated with diabetes in obese women with FPG <7 mmol/L were age (per 10 years: OR 1.54 [1.00-2.11]; P=0.049) and FPG (OR 6.1 [1.4-30.0]; P=0.014), whereas age (OR 1.26 [1.09-1.44]; P<0.01) and waist circumference (per 10 cm: OR 1.17 [1.01-1.33]; P<0.05) were independently associated with dysglycaemia in obese women with FPG <6.1 mmol/L. CONCLUSION In overweight and obese patients: dysglycaemia is commonly seen; FPG alone, compared with OGTT, failed to diagnose 70% of dysglycaemia cases; FPG >5.5 mmol/L and HbA(1c) ≥ 6.0% are not necessarily substitutes for OGTT; and older age and larger waist circumference should be used to select those obese women with normal FPG who might further benefit from OGTTs to diagnose dysglycaemia.

The Diagnostic and Prognostic Performance of a Selective Screening Strategy for Gestational Diabetes Mellitus According to Ethnicity in Europe

CONTEXT The performance of standard selective screening strategies for gestational diabetes mellitus (GDM) may vary according to ethnicity. OBJECTIVE We aimed to evaluate the diagnostic and prognostic performance of a selective screening tool to determine whether it accurately predicts GDM and events in women of different ethnicities. The tool selectively screens based on patients having one or more of the following risk factors (RFs): body mass index ≥25 kg/m(2), age ≥35 years, family history of diabetes, and personal history of GDM or macrosomia. DESIGN AND SETTING We conducted an observational prospective study at a university hospital. PARTICIPANTS We included 17 344 women of European (30.9%), North African (29.6%), Sub-Saharan African (22.2%), Caribbean (8.7%), Indian-Pakistani-Sri Lankan (5.5%), and Asian (3.3%) ethnicities who were without pregravid diabetes and had singleton deliveries (2002-2010). MAIN OUTCOME MEASURES We universally screened GDM and GDM-related events (pre-eclampsia, birth weight ≥4000 g, or dystocia). RESULTS Independent of confounding factors, North African (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.21-1.52; P < .001) and Indian-Pakistani-Sri Lankan (OR, 2.52; 95% CI, 2.13-3.00; P < .001) women had more GDM than Europeans, whereas Sub-Saharan African women had less (OR, 0.82; 95% CI, 0.71-0.94; P < .01). Having one or more RFs was associated with GDM among Europeans (OR, 1.45; 95% CI, 1.22-1.76), North African (OR, 1.33; 95% CI, 1.13-1.55), Sub-Saharan African (OR, 1.48; 95% CI, 1.20-1.83), and Caribbean (OR, 1.55; 95% CI, 1.12-2.14) women. Having one or more RFs was also associated with GDM-related events only in European (P < .01) and North African (P < .05) women, with the following incidences in Europeans: no GDM/no RF, 6.9%; no GDM/RF, 9.0%; GDM/no RF, 14.7%; and GDM/RF, 12.6%. CONCLUSION Standard selective screening criteria were not predictive of GDM in women from India-Pakistan-Sri Lanka and Asia and were associated with GDM-related events only in European and North African women. However, the women with GDM, who were routinely treated, had a poor prognosis, even for those free of RFs. These results support universal screening, irrespective of ethnicity.

Glycation Gap Is Associated With Macroproteinuria but Not With Other Complications in Patients With Type 2 Diabetes

OBJECTIVE We investigated whether glycation gap (G-Gap), an index of intracellular glycation of proteins, was associated with diabetes complications. RESEARCH DESIGN AND METHODS We measured concomitantly HbA1c and fructosamine in 925 patients with type 2 diabetes to calculate the G-Gap, defined as the difference between measured HbA1c, and fructosamine-based predicted HbA1c. Patients were explored for retinopathy, nephropathy, peripheral neuropathy, cardiac autonomic neuropathy (n = 512), and silent myocardial ischemia (n = 506). RESULTS Macroproteinuria was the only complication that was associated with G-Gap (prevalence in the first, second, and third tertile of G-Gap: 2.9, 6.2, and 11.0%, respectively; P < 0.001). The G-Gap was higher in patients with macroproteinuria than in those without (1.06 ± 1.62 vs. 0.03 ± 1.30%; P < 0.0001). Because HbA1c was associated with both G-Gap (HbA1c 7.0 ± 1.4, 7.9 ± 1.4, and 10.1 ± 1.8% in the first, second, and third G-Gap tertile, respectively; P < 0.0001) and macroproteinuria (HbA1c 8.8 ± 2.2% if macroproteinuria, 8.3 ± 2.0% if none; P < 0.05), and because it could have been a confounder, we matched 54 patients with macroproteinuria and 200 patients without for HbA1c. Because macroproteinuria was associated with lower serum albumin and fructosamine levels, which might account for higher G-Gap, we calculated in this subpopulation albumin-indexed fructosamine and G-Gap; macroproteinuria was independently associated with male sex (odds ratio [OR] 3.2 [95% CI 1.5–6.7]; P < 0.01), hypertension (2.9 [1.1–7.5]; P < 0.05), and the third tertile of albumin-indexed G-Gap (2.3 [1.1–4.4]; P < 0.05) in multivariate analysis. CONCLUSIONS In type 2 diabetic patients, G-Gap was associated with macroproteinuria, independently of HbA1c, albumin levels, and confounding factors, suggesting a specific role of intracellular glycation susceptibility on kidney glomerular changes.

Use of clinical scores to detect dysglycaemia in overweight or obese women

AIMS To test if the use of either HbA(1c) level or calculated clinical scores including two published scores and a new score (the Bondy score) could help in selecting overweight or obese women who should benefit from oral glucose tolerance test (OGTT) to detect dysglycaemia. METHODS The French Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) score and the Finnish Diabetes risk score (Findrisk) were calculated, whereas the Bondy score was built in a development sample of 698 women, BMI 37±7 kg/m(2), without known diabetes. External validation was performed in a validation sample of 212 women. RESULTS A dysglycaemia (according to OGTT results, WHO criteria) was diagnosed in 161 (23.1%) patients. Sensitivity of fasting plasma glucose (FPG)≥6.1 mmol/l and HbA(1c)≥6% to identify dysglycaemia were respectively 27 and 41%. Areas under Receiver Operator Curve (AROC) of HbA(1c), DESIR score and Findrisk to detect dysglycaemia were 0.630 [95% confidence interval 0.580-0.680], 0.606 [0.561-0.652] and 0.635 [0.588-0.683], respectively. The Bondy score, based on age and waist circumference, had a better AROC (0.674 [0.626-0.721]) than the DESIR score (P<0.05). These performances were confirmed in the validation sample. Performing OGTT only in subjects with a Bondy score≥4 (41% of the sample) had a sensitivity of 61% and a better net benefit (0.128) than measuring FPG in all subjects (0.069). CONCLUSION Performing OGTT in obese women selected on a simple clinical score is more sensitive to identify dysglycaemia than measuring FPG in all of them and may be cost-effective.

Fetal gender is not associated with either gestational diabetes mellitus or placental weight: A cohort study

AIM This study assessed whether male fetal gender increases the risk of maternal gestational diabetes mellitus (GDM) and investigated the association with placental weight. METHODS The study included 20,149 women without pregestational diabetes who delivered singletons at our hospital between January 2002 and December 2010. There was universal screening for GDM, and all placentas were weighed at delivery. RESULTS GDM (affecting 14.2% of women) was not associated with fetal gender (male fetuses in women without and with GDM: 51.8% vs. 51.7%, respectively; P=0.957), and remained likewise after logistic-regression analysis of risk factors for GDM (OR: 1.007, 95% CI: 0.930-1.091; P=0.858). Placental weights were 600±126g, 596±123g, 584±118g and 587±181g in women with GDM/female, GDM/male, no GDM/female and no GDM/male fetuses, respectively (GDM effect: P=0.017; gender effect: P=0.41; GDM * gender effect: P=0.16). CONCLUSION The present results suggest that fetal gender is not associated with GDM and, while placental weights were higher in cases of GDM, there were still no gender effects.

P36 - Rôle de l’ischémie et de la neuropathie autonome cardiaque dans les altérations de la fonction myocardique chez les patients diabétiques asymptomatiques

Introduction L’alteration de la fonction myocardique du diabetique est d’origine multifactorielle mais peu d’etudes ont evalue le role de l’ischemie myocardique silencieuse (IMS), atteinte microcirculatoire eventuellement associee a des stenoses coronaires (SC), et de la neuropathie autonome cardiaque (NAC). Patients et methodes Nous avons realise une echocardiographie trans-thoracique chez 293 patients, diabetiques depuis 14 ± 7 ans, 172 hommes, 57,8 ± 8,8 ans, asymptomatiques au plan coronarien et sans insuffisance cardiaque clinique mais presentant d’autres facteurs de risque cardiovasculaire. La fonction systolique du ventricule gauche ; la fonction diastolique : E/A mitral, onde ea a l’anneau mitral, E/ea, Vp, E/Vp et 2 indices de performance precocement alteres : l’onde s a l’anneau mitral et l’index de Tei, ont ete mesurees. Une NAC a ete definie par ≥ 1 test anormal parmi 3 tests (respiration profonde, orthostatisme, Valsalva) evaluant la variabilite de la frequence cardiaque. Une scintigraphie myocardique et/ou une echographie cardiaque de stress permettait d’identifier l’IMS. Une coronarographie etait effectuee si l’une de ces epreuves non invasives etait anormale. Resultats Une IMS et une NAC etaient presentes respectivement chez 98 (33,6%) et 183 (62,5%) patients. La presence de SC en cas d’IMS (31 patients) n’etait pas associee a la presence d’une NAC. Les patients avec IMS et/ou NAC avaient une fonction systolique globale (fraction d’ejection : NAC-IMS-/NAC-IMS + / NAC + IMS-/NAC + IMS + 69±6/68±6/67±6/ 64±11% respectivement, p Conclusion Chez les diabetiques asymptomatiques a haut risque cardiovasculaire, l’association IMS/NAC participe a la degradation de la fonction systolique et de la relaxation ventriculaires gauches.

O4 Intérêt de la revascularisation de la maladie coronaire silencieuse chez le diabétique : une étude rétrospective

Introduction L’interet de la revascularisation est debattu dans la maladie coronaire stable comme dans la coronaropathie silencieuse (CS) chez le diabetique. L’objectif etait de determiner dans une etude retrospective si le pronostic des diabetiques avec CS etait meilleur en cas de revascularisation. Patients et Methodes L’etude porte sur les 93 patients (69 hommes, 61 ± 8 ans, diabetiques depuis 13+8 ans) presentant une CS (stenose coronaire > 70 %) au sein d’une serie de 788 patients asymptomatiques presentant au moins un facteur de risque cardio-vasculaire (nephropathie 43 %, hypertension 76,3 %, dyslipidemie 71,7, tabagisme 35,5 %, autre atteinte arterielle 19,4 %, antecedents familiaux precoces 9,1 %) qui avaient ete depistes pour une ischemie myocardique silencieuse par scintigraphie de stress entre 1992 et 2008 et coronarographie en cas de positivite. Parmi ces 93 patients, 50 avaient des lesions monotronculaires et 16 des lesions tritronculaires. Tous ces patients ont ete suivis pour le premier evenement cardiaque (EC) et l’incidence des EC a ete comparee chez ceux qui avaient eu, sur decision de l’equipe cardiologique, une revascularisation initiale (groupe REVASC : 29 angioplasties, 7 pontages) ou non (groupe MED : n = 57). Resultats La proportion d’hommes etait plus importante dans le groupe REVASC que dans le groupe MED (83,3 vs 53,6 %, p Discussion Ces resultats sont a confirmer par une etude prospective randomisee, testant en particulier les angioplasties avec stent actif. Conclusion Le taux d’EC est tres eleve chez les diabetiques avec CS. Les pontages chez les patients tritronculaires s’accompagnent d’un meilleur pronostic.

P276 Rôle d’une dysfonction autonome cardiaque dans l’insulinorésistance et l’élévation tensionnelle chez les obèses

Introduction Le role de l’insulinoresistance (IR) a ete evoque dans la dysfonction autonome cardiaque (DAC) chez les diabetiques de type 2. L’obesite est souvent associee a une DAC. Le but etait, chez les obeses sans diabete connu, d’evaluer le role de l’IR dans la DAC et si les alterations metaboliques sont plus marquees et la pression arterielle plus elevee chez les patients avec a la fois IR et DAC. Patients et Methodes Nous avons inclus 394 patients obeses ou en surpoids (IMC 38,5 ± 7 kg/m2), âges de 38,1 ± 14,4 ans. Une charge en glucose a ete effectuee et l’index HOMA d’IR a ete calcule. Un syndrome metabolique a ete affirme selon les criteres IDF. Une DAC a ete definie par au moins un test anormal parmi 3 tests (respiration profonde, orthostatisme, Valsalva), sous dependance vagale predominante, evaluant la variabilite de la frequence cardiaque, la DAC etant consideree severe si 2 ou 3 tests etaient anormaux. Resultats Une DAC etait presente chez 213 patients. L’IR definie par un HOMA = 2,93 (valeur mediane) etait associee a la DAC (63 % vs 49 % chez les patients avec HOMA Conclusion Chez les obeses sans diabete connu, 1. L’IR est associee a une prevalence plus elevee de DAC et a une DAC plus severe, 2. La presence d’une DAC, du fait d’une predominance sympathique, pourrait contribuer a l’IR et aggraver les consequences de l’IR sur les desordres metaboliques notamment la dysregulation glycemique et sur la pression et la rigidite arterielles.

O92 HbA1c, seuil de glycémie à jeun moindre et recommandations de l’Agence Nationale d’Accréditation et d’Évaluation des Soins (ANAES) ne peuvent pas se substituer à la charge en glucose pour le diagnostic des dysglycémies

Introduction La charge orale en glucose (COG) n’est actuellement pas recommandee en France pour le diagnostic des dysglycemies. Des methodes de substitution ont ete proposees, comme diminuer le seuil de glycemie a jeun (GAJ), doser l’HbA1c et selectionner la population a depister. L’objectif de l’etude etait de determiner la prevalence des dysglycemies meconnues, incluant le diabete, l’hyperglycemie a jeun (HAJ) et l’intolerance au glucose (IG) dans une cohorte importante de patients en surpoids ou obeses ; l’efficacite de ces methodes de substitution ; et les principaux facteurs predictifs de dysglycemie dans cette population. Patients et Methodes Une COG a ete realisee chez 1 283 patients sans dysglycemie connue hospitalises pour surpoids ou obesite. Resultats Un etat pre-diabetique a ete diagnostique chez 257 (20 %) patients (197 IG, 29 HAJ et 31 IG+HAJ) et un diabete chez 77 (6 %) patients, dont 22 avec une GAJ = 7 mmol/l. Une GAJ = 6 mmol/l, une GAJ = 5,5 mmol/l, une HbA1c = 6 % et suivre les recommandations de l’ANAES auraient respectivement identifie 29,9 ; 41,3 ; 36,8 et 15,6 % des patients avec une COG anormale. Les facteurs predictifs independants de dysglycemie en analyse multivariee etaient l’âge (odds ratio 1,031 [intervalle de confiance a 95 % : 1,018–1,044], p Conclusion Chez les patients en surpoids ou obeses, a- la prevalence des dysglycemies est elevee ; b- la GAJseule comparee a la COGne diagnostique que 31 % des diabetes ou prediabetes ; c- une GAJ > 5,5 mmol/L et une HbA1c = 6,0 % ne peuvent pas se substituer a la COG ; d- les facteurs predictifs principaux de dysglycemie sont l’âge, le tour de taille et l’hypertension et pourraient etre utilises en priorite pour la selection des sujets a depister.