Luc Millot

Assessment of Patient-Led or Physician-Driven Continuous Glucose Monitoring in Patients With Poorly Controlled Type 1 Diabetes Using Basal-Bolus Insulin Regimens A 1-year multicenter study

OBJECTIVE The benefits of real-time continuous glucose monitoring (CGM) have been demonstrated in patients with type 1 diabetes. Our aim was to compare the effect of two modes of use of CGM, patient led or physician driven, for 1 year in subjects with poorly controlled type 1 diabetes. RESEARCH DESIGN AND METHODS Patients with type 1 diabetes aged 8–60 years with HbA1c ≥8% were randomly assigned to three groups (1:1:1). Outcomes for glucose control were assessed at 1 year for two modes of CGM (group 1: patient led; group 2: physician driven) versus conventional self-monitoring of blood glucose (group 3: control). RESULTS A total of 257 subjects with type 1 diabetes underwent screening. Of these, 197 were randomized, with 178 patients completing the study (age: 36 ± 14 years; HbA1c: 8.9 ± 0.9%). HbA1c improved similarly in both CGM groups and was reduced compared with the control group (group 1 vs. group 3: −0.52%, P = 0.0006; group 2 vs. group 3: −0.47%, P = 0.0008; groups 1 + 2 vs. group 3: −0.50%, P < 0.0001). The incidence of hypoglycemia was similar in the three groups. Patient SF-36 questionnaire physical health score improved in both experimental CGM groups (P = 0.004). Sensor consumption was 34% lower in group 2 than in group 1 (median [Q1–Q3] consumption: group 1: 3.42/month [2.20–3.91] vs. group 2: 2.25/month [1.27–2.99], P = 0.001). CONCLUSIONS Both patient-led and physician-driven CGM provide similar long-term improvement in glucose control in patients with poorly controlled type 1 diabetes, but the physician-driven CGM mode used fewer sensors.

Alteration of the QT rate dependence in anorexia nervosa

Myocardial repolarization has been evaluated in patients with anorexia nervosa (AN) with conflicting results. The authors postulated that dynamic alterations in QT interval adaptation could characterize these patients. This study compared QT dynamicity along RR intervals from 24‐hour ECG data of patients with and without AN. Twenty‐five patients (23 women) fulfilling the Diagnostic and Statistical Manual (DSM IV) criteria for AN were included in the study. All underwent 24‐hour ECG Holter recordings, allowing QT and RR measurements, and heart rate variability (HRV) analysis in free‐living conditions. A group of 25 sex‐ and age‐matched healthy subjects served as controls. Compared with controls, AN patients presented with relative bradycardia, more particularly during night periods but neither mean QT nor corrected mean QT length (calculated using Bazett formula) over the 24 hours of monitoring differed. However, QT/RR slope was found significantly enhanced compared with normals (− 2.00 ± 0.53 vs − 1.42 ± 0.40) (P = 0.006): QT length related to heart rate was found longer for a heart rate <55 beats/min in AN. Mean 24‐hours QT length appears unaltered in AN in the absence of electrolytic disorders. However, the QT/RR relationship was enhanced reflecting the specific autonomic imbalance encountered in this population. The clinical implications of such findings need to be discussed since an equivalent enhancement of QT/RR slope has been described after myocardial infarction in patients presenting life‐threatening ventricular arrhythmias.

Diminution de la mortalité et stabilité du taux de guérison dans le suivi de l’anorexie mentale

Resume Objectif L’anorexie mentale (AM) est un trouble du comportement alimentaire associant une denutrition, une amenorrhee et un trouble de l’image corporelle selon les criteres du DSM-IV. Peu d’etudes de suivi ont ete publiees. Nous avons realise une etude retrospective, portant sur la population de patientes anorexiques mentales restrictives ayant ete prises en charge de 1979 a 2004. Methodes Les donnees necessaires, elaborees a partir de l’inventaire de Morgan et Russell, ont ete recueillies entre mai et juillet 2004 a l’aide du dossier clinique et d’une enquete telephonique. Pour chaque patiente, ont ete notes la chronologie de la maladie, les caracteristiques morphologiques, le type de l’anorexie, le mode de prise en charge, l’histoire gynecologique et la situation professionnelle et conjugale. Resultats La population etudiee representait 206 patientes pour lesquelles la duree moyenne de suivi a ete de 8,3 ± 5,3 ans ; 55,8 % ont ete gueries sur les criteres IMC > 17,5 kg/m2 maintenu pendant 1 an et reprise de l’activite genitale ; 18,5 % sont entrees dans une forme chronique de la maladie et 25,7 % avaient encore une des deux composantes citees ci-dessus. Le taux de mortalite a ete de 1,8 %. En termes d’evolution de la maladie, l’âge de debut precoce lors de l’adolescence etait de bon pronostic. Par contre, l’intensite de la maigreur, un delai de prise en charge long, une frequence faible de consultation semblaient predictifs d’une issue defavorable. Conclusions La gravite de cette maladie est plutot liee a ses formes chronicisees qu’au nombre de deces qui lui sont directement imputables. Par contre, le versant psychopathologique n’a pas ete pris en compte et il semble important a evaluer puisque certains traits de personnalite sous-jacents apparaissent comme des facteurs de comorbidite.

Chronotropic incompetence to exercise separates low body weight from established anorexia nervosa.

Chronotropic incompetence (CI), characterized by an attenuated heart rate (HR) response to exercise could participate to the limitation of exercise capacity in anorexia nervosa (AN). Therefore, we evaluated the role of cardiac sympathetic responsiveness in AN patients. In addition, the ambulatory value of autonomic control using spectral analysis of heart rate variability (HRV) was determined and correlated to maximal exercise performance. Twenty‐two patients hospitalized for weight loss and suspicion of AN were included in the study. All performed a symptom‐limited exercise test with measurement of gas exchange for chronotropic response to exercise evaluation. Holter ECG recordings allowed daytime and night‐time spectral domain HRV analysis in order to evaluate the alteration of sympathetic control of HR in free‐living conditions. CI defined as a failure to achieve 80% of heart rate reserve (%HRR) was observed in 13 (59%) patients (CI+). This group presented a higher body mass deficit than the group without CI (CI−; −35·1 ± 8·7% versus −26·1 ± 10·7%; P<0·05). Obviously, patients with a lower body mass index (BMI < 16 kg m−2, n = 14) revealed a more severe limitation to maximal exercise with a lower peak HR, a lower peak Vo2, and a lower maximal O2 pulse (P<0·05). BMI was significantly correlated to peak Vo2, maximal HR, and %HRR achieved at peak exercise. Daytime HRV parameters reflecting the sympathetic autonomic equilibrium (LF nu, LF/HF ratio) were significantly lower in CI+ patients. Blunted sympathetic response to maximal exercise is frequent and correlated to weight deficit. The present data suggest a major autonomic derangement in AN characterized by a cardiac sympathetic withdrawal.

No Loss of Chance of Diabetic Retinopathy Screening by Endocrinologists With a Digital Fundus Camera

OBJECTIVE To compare the efficacy of the diabetic retinopathy (DR) screening with digital camera by endocrinologists with that by specialist and resident ophthalmologists in terms of sensitivity, specificity, and level of “loss of chance.” RESEARCH DESIGN AND METHODS In a cross-sectional study, 500 adult diabetic patients (1,000 eyes) underwent three-field retinal photography with a digital fundus camera following pupillary dilatation. Five endocrinologists and two ophthalmology residents underwent 40 h of training on screening and grading of DR and detection of associated retinal findings. A κ test compared the accuracy of endocrinologist and ophthalmology resident screening with that performed by experienced ophthalmologists. Screening efficiency of endocrinologists was evaluated in terms of “loss of chance,” i.e., missed diagnoses that required ophthalmologist referrals. RESULTS The mean weighted κ of DR screening performed by endocronologists was similar to that of ophthalmology residents (0.65 vs. 0.73). Out of 456 DR eyes, both endocrinologists and ophthalmology residents misdiagnosed only stage 1 DR (36 and 14, respectively), which did not require ophthalmologist referral. There were no significant differences between endocrinologists and ophthalmology residents in terms of diabetic maculopathy and incidental findings except for papillary cupping and choroidal lesions, which were not the main purpose of the study or of the training. CONCLUSIONS The endocrinologist with specific training for DR detection using a three-field digital fundus camera with pupillary dilatation can perform a reliable DR screening without any loss of chance for the patients when compared with identical evaluation performed by experienced ophthalmologists.

Are third-trimester adipokines associated with higher metabolic risk among women with gestational diabetes?

AIM This study aimed to determine whether third-trimester adipokines during gestational diabetes (GDM) are associated with higher metabolic risk. METHODS A total of 221 women with GDM (according to IADPSG criteria) were enrolled between 2011/11 and 2013/6 into a prospective observational study (IMAGE), and categorized as having elevated fasting blood glucose (FBG) or impaired fasting glucose (IFG, n = 36) if levels were ≥ 92 mg/dL during a 75-g oral glucose tolerance test (OGTT), impaired glucose tolerance (IGT, n = 116) if FBG was < 92 mg/dL but with elevated 1-h or 2-h OGTT values, or impaired fasting and stimulated blood glucose (IFSG, n = 69) if both FBG was ≥ 92 mg/dL and 1-h or 2-h OGTT values were elevated. RESULTS Pre-gestational body mass index (BMI) was higher in women with IFG or IFSG compared with IGT (P < 0.001), as were leptin levels in women with IFG vs IGT [34.7 (10.5-119.7) vs 26.6 (3.56-79.4) ng/L; P = 0.008]. HOMA2-IR scores were higher in women with IFG or IFSG vs IGT (1.87 ± 1.2 or 1.72 ± 0.9 vs 1.18 ± 0.8, respectively; P < 0.001). Also, those with IFSG vs those with IGT had significantly lower HOMA2-B scores (111.4 ± 41.3 vs 127.1 ± 61.6, respectively; P < 0.05) and adiponectin levels [5.00 (1.11-11.3) vs 6.19 (2.11-17.7) μg/mL; P < 0.001], and higher levels of IL-6 [1.14 (0.33-20.0) vs 0.90 (0.31-19.0); P = 0.012] and TNF-α [0.99 (0.50-10.5) vs 0.84 (0.45-11.5) pg/mL; P = 0.003]. After adjusting for age, parity, and pre-gestational and gestational BMI, the difference in adiponectin levels remained significant. CONCLUSION Diagnosing GDM by IADSPG criteria results in a wide range of heterogeneity. Our study has indicated that adipokine levels in addition to FBG may help to select women at high metabolic risk for appropriate monitoring and post-delivery interventions (ClinicalTrials.gov number NCP02133729).