Nawal El Ansari

Iodine Supplementation Decreases Hypercholesterolemia in Iodine-Deficient, Overweight Women: A Randomized Controlled Trial

BACKGROUND In iodine deficiency, thyrotropin (TSH) may increase to stimulate thyroidal iodine uptake. In iodine-sufficient populations, higher TSH predicts higher total cholesterol. Whether higher TSH caused by iodine deficiency affects serum lipids is uncertain. OBJECTIVE Our aim was to determine if iodine repletion decreases serum TSH and improves the lipid profile. METHODS In this randomized controlled intervention, iodine-deficient, overweight or obese Moroccan women (n = 163) received 200 μg oral iodine or a placebo daily for 6 mo. Main outcomes were serum TSH and plasma total and LDL cholesterol. Secondary outcomes included thyroid hormones and measures of lipid and glucose metabolism and urinary iodine concentration (UIC). Data were compared by using mixed-model analysis. RESULTS In the intervention group, median UIC increased from 38 (95% CI: 34, 45) μg/L to 77 (95% CI: 59, 89) μg/L (P < 0.001). After 6 mo of intervention, TSH was 33% lower in the treatment group than in the placebo group (P = 0.024). The triiodothyronine (T3) to thyroxine (T4) ratio and thyroglobulin decreased with treatment [-15% (P = 0.002) and -32% (P < 0.001), respectively], whereas T4 concentrations were higher in the treatment group (P < 0.001). Total cholesterol in subjects with elevated baseline cholesterol (>5 mmol/L) was reduced by 11% after the intervention (P = 0.034). At 6 mo, only 21.5% of treated women remained hypercholesterolemic (total cholesterol >5 mmol/L) vs. 34.8% of controls (baseline: 44.2% in the intervention and 36.8% in the control group; P = 0.015). The reduction in the prevalence of elevated LDL cholesterol (>3 mmol/L) in the intervention group (50.6% to 35.4% compared with 47.4% to 44.9% in the control group) was not significant (P-interaction = 0.23). CONCLUSIONS Our findings suggest that moderate to severe iodine deficiency in overweight women elevates serum TSH and produces a more atherogenic lipid profile and that iodine supplementation in this group reduces the prevalence of hypercholesterolemia. Thus, iodine prophylaxis may reduce cardiovascular disease risk in overweight adults. This trial was registered at clinicaltrials.gov as NCT01985204.

Management of diabetes in Morocco: results of the International Diabetes Management Practices Study (IDMPS) – wave 5

Objectives: The International Diabetes Mellitus Practice Study (IDMPS) is a 5-year survey documenting changes in diabetes treatment practices in developing countries. The primary objective of this survey was to assess the therapeutic management of type 2 diabetes mellitus (T2DM) in real-life medical practice. The secondary objectives were to evaluate the clinical management of type 1 diabetes mellitus (T1DM) and to assess the proportion of all diabetic patients failing to reach the glycated haemoglobin (HbA1c) <7% target. Methods: Data were analysed for 738 patients (240 with T1DM and 498 with T2DM) included in wave 5 of the IDMPS in Morocco in 2011. Results: Nearly two-thirds (61%) of T2DM patients were treated with oral glucose-lowering drugs (OGLDs) alone, 13.1% were treated with insulin alone and 23.3% were treated with OGLDs plus insulin. Insulin use was less frequent, was initiated later and involved a greater use of premixes versus basal/prandial schedules compared to other populations evaluated in the IDMPS. The majority (92.5%) of T1DM patients were treated with insulin alone and the remainder received insulin plus an OGLD. Insulin protocols included basal + prandial dosing (37.5%) and premix preparations (41.3%). The recommended target of HbA1c <7% was achieved by only 22.2% of T1DM patients and 26.8% of T2DM patients. More macrovascular but fewer microvascular complications were reported in T2DM compared to T1DM patients. Late complications increased with disease duration so that 20 years after diagnosis, 75.7% of T2DM patients were found to have at least one late complication. Conclusions: The clinical burden of diabetes is high in Morocco and the majority of patients do not achieve the recommended glycaemia target, suggesting that there is a huge gap between evidence-based diabetic management and real-life practice. Better education of patients and improved compliance with international recommendations are necessary to deliver a better quality of diabetic care.

Pituitary apoplexy during pregnancy.

The pituitary apoplexy is a rare and fatal complication of the pituitary adenoma; it represents 0.6 to 10%. This is a clinical syndrome resulting from a fulminant pituitary expansion due to a bleeding and\or a pituitary infarcissement. We report the case of a 29-year-old patient who consults for an amenorrhoea with spontaneous galactorrhea and chronic headaches evolving over 7 months. The balance sheet of the amenorrhoea discovers a hyperprolactinemia in 224ng / ml treated by Bromocriptine without etiological survey. The patient had a pregnancy, and in 19 weeks of amenorrhoea, she presents of rough installation of the rebel headaches with visual disorders (blindness of the right eye). The magnetic resonance imaging (MRI) was in favour of a stroke of the pituitary macro-adenoma (A and B). The prolactin was always brought up. The patient was treated by Cabergoline. The evolution was favorable, with complete regression of the visual disorders after one month of treatment. The MRI of control shows the total disappearance of the leaving expansive process place in an intracellair arachnoidocele (C and D). The clinical demonstrations of the pituitaire stroke are essentially represented by the tumoral syndrome, the visual disorders and the disorders of consciousness. The MRI is the examination of choice. In the case reported radiographic appearance was typical of a pituitary apoplexy.

Improving detection and initial management of gestational diabetes through the primary level of care in Morocco: protocol for a cluster randomized controlled trial

BackgroundMorocco is facing a growing prevalence of diabetes and according to latest figures of the World Health Organization, already 12.4% of the population are affected. A similar prevalence has been reported for gestational diabetes (GDM) and although it is not yet high on the national agenda, immediate and long-term complications threaten the health of mothers and future generations. A situational analysis on GDM conducted in 2015 revealed difficulties in access to screening and delays in receiving appropriate care. This implementation study has as objective to evaluate a decentralized GDM detection and management approach through the primary level of care and assess its potential for scaling up.MethodsWe will conduct a hybrid effectiveness-implementation research using a cluster randomized controlled trial design in two districts of Morocco. Using the health center as unit of randomization we randomly selected 20 health centers with 10 serving as intervention and 10 as control facilities. In the intervention arm, providers will screen pregnant women attending antenatal care for GDM by capillary glucose testing during antenatal care. Women tested positive will receive nutritional counselling and will be followed up through the health center. In the control facilities, screening and initial management of GDM will follow standard practice. Primary outcome will be birthweight with weight gain during pregnancy, average glucose levels and pregnancy outcomes including mode of delivery, presence or absence of obstetric or newborn complications and the prevalence of GDM at health center level as secondary outcomes. Furthermore we will assess the quality of life /care experienced by the women in both arms. Qualitative methods will be applied to evaluate the feasibility of the intervention at primary level and its adoption by the health care providers.DiscussionIn Morocco, gestational diabetes screening and its initial management is fragmented and coupled with difficulties in access and treatment delays. Implementation of a strategy that enables detection, management and follow-up of affected women at primary health care level is expected to positively impact on access to care and medical outcomes.Trial registrationThe trial has been registered on clininicaltrials.gov; identifier NCT02979756; retrospectively registered 22 November 2016.

Association of newly diagnosed type 1 diabetes and autoimmune pancreatitis

Summary Autoimmune pancreatitis is a new nosological entity in which a lymphocytic infiltration of the exocrine pancreas is involved. The concomitant onset of autoimmune pancreatitis and type 1 diabetes has been recently described suggesting a unique immune disturbance that compromises the pancreatic endocrine and exocrine functions. We report a case of type1 diabetes onset associated with an autoimmune pancreatitis in a young patient who seemed to present a type 2 autoimmune polyglandular syndrome. This rare association offers the opportunity to better understand pancreatic autoimmune disorders in type 1 diabetes. Learning points: The case makes it possible to understand the possibility of a simultaneous disturbance of the endocrine and exocrine function of the same organ by one autoimmune process. The diagnosis of type 1 diabetes should make practitioner seek other autoimmune diseases. It is recommended to screen for autoimmune thyroiditis and celiac diseases. We draw attention to consider the autoimmune origin of a pancreatitis associated to type1 diabetes. Autoimmune pancreatitis is a novel rare entity that should be known as it is part of the IgG4-related disease spectrum.

Fatal hypoglycaemia from IGF II hyperproduction as a complication of a mesenteric gastrointestinal stromal tumour

a Gastroenterology Department, King Mohamed VI Hospital, FMPM, UCAM, King Mohamed VI University Hospital, Medical School of Marrakech, Cadi Ayyad University, Marrakech, Morocco b Surgery Department, King Mohamed VI Hospital, FMPM, UCAM, King Mohamed VI University Hospital, Medical School of Marrakech, Cadi Ayyad University, Marrakech, Morocco c Endocrinology Department, King Mohamed VI Hospital, FMPM, UCAM, King Mohamed VI University Hospital, Medical School of Marrakech, Cadi Ayyad University, Marrakech, Morocco d Anatomical Pathology Department, King Mohamed VI Hospital, FMPM, UCAM, King Mohamed VI University Hospital, Medical School of Marrakech, Cadi Ayyad University, Marrakech, Morocco

Necrobiosis lipoidica: a rare complication of diabetes

We report the case of a 21-year-old patient, known as a type 1 diabetic for 11 years on insulin therapy, who for the past 4 years has had a skin lesion that is progressively increasing in size on the anterior aspect of the left leg. The clinical examination revealed a sclero-atrophic cupboard with erythematous border on the anterior aspect of the leg. A skin biopsy was made revealing a morphological appearance compatible with necrobiosis lipoidica. Necrobiosis Lipoidica is a rare cutaneous manifestation, the prevalence of which is estimated at 0.3% in diabetics. The lesions are characterized by confluent papules in irregular patches, mainly on the anterior surface of the legs, installed bilaterally and symmetrically. Other locations are rarer: scalp, face, arm and trunk. The edges are infiltrated. The lesions evolve most often towards a central ulceration. The pathophysiology is hypothetical and the lesions could be due to cutaneous microangiopathy. It is associated with type 1 or 2 diabetes, excluding an autoimmune origin. Therapeutically, remission can be spontaneous. No treatment has been shown to be effective. Local corticosteroids under occlusion are proposed for recent lesions, but not for atrophic lesions as they may precipitate ulceration.

Un cas de phéochromocytome découvert au cours d’une grossesse gémellaire: un diagnostic à ne pas méconnaitre et revue de littérature

The pheochromocytoma is a rare, but potentially serious, which can be revealed by pregnancy. Less than 250 cases described in the literature .The rarity of this association and similarity with pregnancy-induced hypertension explains the frequency of unknown diagnoses during pregnancy. A privileged time of discovery, the prognosis associated with early diagnosis, a multidisciplinary management. Hence the need to explore all arterial hypertension poorly defined or family nature during pregnancy. The certainty diagnosis is conducted by biological tests provided are thought of, a review of localization by ultrasound or magnetic resonance imaging (MRI), a medical preparation can choose according to the term to remove the tumor before or after delivery. We related a case of pheochromocytoma diagnosed during a twin pregnancy of 26 weeks of amenorrhea (SA), bringing us the elements of the clinical and laboratory diagnostic imaging, treatment and maternal and fetal prognosis.

Scleroderma and type 1 diabetes: a rare association

The association of type 1 diabetes and systemic scleroderma is rarely reported in the literature, the pathogenesis of this association is unknown, interferon seems to have a major role in being an immunomodulator and inhibitor of collagen production, and it is also involved in autoimmune pathology. Note that this association could be at the origin of a difficulty of passage of the insulin in the sites of injections, responsible for a major glycemic imbalance. We report the case of a 26-year-old patient, who had been diabetic for 6 years on insulin, who was referred for a glycemic imbalance, who had a clinical examination objectifying multiple morphea lesions on the roots of the thighs, arms, abdomen and thorax. A cutaneous biopsy was performed, showing a sclerodermiform appearance with significant fibrosis without sign of malignancy, result rather in favor of a scleroderma.

Familial hypercholesterolemia revealed by multiple xanthomas

Familial hypercholesterolemia (HF) is a rare pathology characterized by a major elevation of LDL associated with tendinous and subcutaneous xanthomas. We report the case of a 16-year-old patient, born from a first degree consanguineous marriage, with no particular pathological antecedents, the patient reports appearance for 9 years of cutaneous lesions described as a swellings in the posterior face of the 2 elbows and the anterior surface of the 2 knees, painless, firm, and gradually increasing in volume. The patient consulted only at the age of 16 years in front of the aesthetic discomfort. The biological assessment objectified a hypercholesterolemia: total Cholesterol: 4.44g/l. HDL: 0.64g/l. LDL: 3.71g/l. and Triglycerides: 0.67g/l. The exploration of cardiac repercussion was without particularities.The patient was treated with dietary and lifestyle measures and atorvastatin 80 mg with good clinical and biological evolution.