Diagnostic performance of FibroTest, SteatoTest and ActiTest in patients with NAFLD using the SAF score as histological reference

BACKGROUND: Blood tests of liver injury are less well validated in non‐alcoholic fatty liver disease (NAFLD) than in patients with chronic viral hepatitis. AIMS: To improve the validation of three blood tests used in NAFLD patients, FibroTest for fibrosis staging, SteatoTest for steatosis grading and ActiTest for inflammation activity grading. METHODS: We pre‐included new NAFLD patients with biopsy and blood tests from a single‐centre cohort (FibroFrance) and from the multicentre FLIP consortium. Contemporaneous biopsies were blindly assessed using the new steatosis, activity and fibrosis (SAF) score, which provides a reliable and reproducible diagnosis and grading/staging of the three elementary features of NAFLD (steatosis, inflammatory activity) and fibrosis with reduced interobserver variability. We used nonbinary‐ROC (NonBinAUROC) as the main endpoint to prevent spectrum effect and multiple testing. RESULTS: A total of 600 patients with reliable tests and biopsies were included. The mean NonBinAUROCs (95% CI) of tests were all significant (P < 0.0001): 0.878 (0.864–0.892) for FibroTest and fibrosis stages, 0.846 (0.830–0.862) for ActiTest and activity grades, and 0.822 (0.804–0.840) for SteatoTest and steatosis grades. FibroTest had a higher NonBinAUROC than BARD (0.836; 0.820–0.852; P = 0.0001), FIB4 (0.845; 0.829–0.861; P = 0.007) but not significantly different than the NAFLD score (0.866; 0.850–0.882; P = 0.26). FibroTest had a significant difference in median values between adjacent stage F2 and stage F1 contrarily to BARD, FIB4 and NAFLD scores (Bonferroni test P < 0.05). CONCLUSIONS: In patients with NAFLD, SteatoTest, ActiTest and FibroTest are non‐invasive tests that offer an alternative to biopsy, and they correlate with the simple grading/staging of the SAF scoring system across the three elementary features of NAFLD: steatosis, inflammatory activity and fibrosis

Grossesse et diabète prégestationnel (étude de 142 femmes suivies dans le service de diabétologie de la Pitié entre 1999 et 2004)

La grossesse chez une femme diabétique est une situation à risque tant sur le plan fœtal que maternel. Nous avons étudié 142 patientes prises en charge consécutivement dans le service de Diabétologie de la Pitié pendant leur grossesse, entre 1999 et 2004, et présentant un diabète prégestationnel : 78 patientes diabétiques de type 1 (55%), et 64 patientes diabétiques de type 2 (45%). Nous avons mis en évidence un taux de malformations, de prématurité et de césariennes respectivement 1.5, 3 et 3 fois plus élevés que dans la population générale, sans augmentation par contre de la mortalité maternelle et périnatale. Le taux de programmation est stable depuis 10 ans : 54% pour les patientes diabétiques de type 1 et 22,2% pour celles de type 2, significativement liés aux caractéristiques sociodémographiques des patientes. Notre travail manque de puissance pour montrer de façon significative un lien entre la programmation et les différents paramètres du pronostic maternel et fœtal. Mais, chez les patientes diabétiques de type 1, la programmation réduit significativement le nombre d'hospitalisations et assure l'obtention d'une meilleure HbA1c tout au long de la grossesse ; une HbA1c préconceptionnelle inférieure ou égale à 7% permet quant à elle de réduire le taux de prématurité, de malformations, et d'hospitalisations. Les taux de macrosomie sont très hétérogènes (de 15 à 28%) selon les définitions employées. L'index pondéral nous paraît être la définition la plus pertinente compte-tenu de son lien avec l'HbA1c des 2ème et 3ème trimestres, et la morbidité néonatale. Un effort particulier est indispensable dans la prise en charge des patientes diabétiques de type 2 : leur prévalence a augmenté de 25% en 10 ans, et il existe un retard au diagnostic (15,6% découvert après la période d'embryogenèse). Nous encourageons le dépistage du diabète chez toutes les femmes ayant des facteurs de risque en âge de procréer, et une adaptation des messages de programmation, également en extra hospitalier, envers une population jusqu'ici peu concernée.PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

How Can Maternal Lifestyle Interventions Modify the Effects of Gestational Diabetes in the Neonate and the Offspring? A Systematic Review of Meta-Analyses

International audienceGestational diabetes (GDM) has deleterious effects on the offspring. Maternal obesity and excessive gestational weight gain (GWG), often associated with diabetes, also contribute to these adverse outcomes.OBJECTIVES:To assess the benefit for the offspring of maternal lifestyle interventions, including diets and physical activity, to prevent or to improve GDM and to limit excessive GWG.METHOD:Systematic review of meta-analyses published in English between December 2014 and November 2019.RESULTS:Lifestyle interventions to reduce the risk of GDM reported a decreased risk of 15% to 40%, with a greater effect of exercise compared to diet. Combined lifestyle interventions specifically designed to limit GWG reduced GWG by 1.6 kg in overweight and obese women, and on average by 0.7 to 1 kg in all pregnant women. In these trials, adverse neonatal outcomes were poorly studied. Combined lifestyle interventions in women with GDM significantly reduced fetal growth. Altogether, lifestyle interventions reduced the risk of preterm birth and shoulder dystocia, but individually, diets or exercise alone had no effect on neonatal adverse outcomes.CONCLUSION:Specific maternal, neonatal and offspring benefits of lifestyle interventions during pregnancy to prevent or improve GDM control or to limit GWG still require clarification

An Overview of Hypoglycemia in the Critically Ill

Hypoglycemia is a common and serious problem among patients with diabetes mellitus. It is also perceived as the most important obstacle to tight glucose control using intensive insulin therapy in critically ill patients. Because glucose is an obligatory metabolic fuel for the brain, hypoglycemia always represents an emergency that signals the inability of the brain to meet its energy needs. When left untreated, hypoglycemia can result in permanent brain damage and ultimately, death. In the context of critical illness that limits endogenous glucose production and increases glucose utilization, inadequate nutrition, or insufficient provision of glucose, intensive insulin therapy is the most frequent cause of hypoglycemia. Neurogenic and neuroglycopenic symptoms of hypoglycemia can remain unknown because of the underlying critical illness and sedation. Thus, close and reliable monitoring of the glycemic level is crucial in detecting hypoglycemia. In prospective randomized controlled studies comparing the effects of two glucose regimens, intensive insulin therapy aimed to reach strict glucose control (<110 mg/dl) but increased the incidence of severe hypoglycemia (<40 mg/dl) by four- to sixfold. Severe hypoglycemia is statistically associated with adverse outcomes in intensive care unit patients, although a direct causal relationship has not been demonstrated

Relative Contribution of Gestational Weight Gain, Gestational Diabetes, and Maternal Obesity to Neonatal Fat Mass

International audienceMaternal nutritional and metabolic status influence fetal growth. This study investigated the contribution of gestational weight gain (GWG), gestational diabetes (GDM), and maternal obesity to birthweight and newborn body fat. It is a secondary analysis of a prospective study including 204 women with a pregestational body mass index (BMI) of 18.5-24.9 kg/m 2 and 219 women with BMI ≥ 30 kg/m 2. GDM was screened in the second and third trimester and was treated by dietary intervention, and insulin if required. Maternal obesity had the greatest effect on skinfolds (+1.4 mm) and cord leptin (+3.5 ng/mL), but no effect on birthweight. GWG was associated with increased birthweight and skinfolds thickness, independently from GDM and maternal obesity. There was an interaction between third trimester weight gain and GDM on birthweight and cord leptin, but not with maternal obesity. On average, +1 kg in third trimester was associated with +13 g in birthweight and with +0.64 ng/mL in cord leptin, and a further 32 g and 0.89 ng/mL increase in diabetic mothers, respectively. Maternal obesity is the main contributor to neonatal body fat. There is an independent association between third trimester weight gain, birthweight, and neonatal body fat, enhanced by GDM despite intensive treatment

Gestational diabetes and adverse perinatal outcomes from 716,152 births in France in 2012

International audienceAims/hypothesis: The aim of this study was to assess the risk of adverse perinatal outcomes in gestational diabetes mellitus (GDM) in a large national cohort.Methods: All deliveries taking place after 22 weeks in France in 2012 were included by extracting data from the hospital discharge database and the national health insurance system. The diabetic status of mothers was determined by the use of glucose-lowering agents and by hospital diagnosis. Outcomes were analysed according to the type of diabetes and, in the GDM group, whether or not diabetes was insulin-treated.Results: The cohort of 796,346 deliveries involved 57,629 (7.24%) mothers with GDM. Mother–infant linkage was obtained for 705,198 deliveries. The risks of adverse outcomes were much lower with GDM than with pregestational diabetes. After limiting the analysis to deliveries after 28 weeks to reduce immortal time bias, the risks of preterm birth (OR 1.3 [95% CI 1.3, 1.4]), Caesarean section (OR 1.4 [95% CI 1.4, 1.4]), pre-eclampsia/eclampsia (OR 1.7 [95% CI 1.6, 1.7]), macrosomia (OR 1.8 [95% CI 1.7, 1.8]), respiratory distress (OR 1.1 [95% CI 1.0, 1.3]), birth trauma (OR 1.3 [95% CI 1.1, 1.5]) and cardiac malformations (OR 1.3 [95% CI 1.1, 1.4]) were increased in women with GDM compared with the non-diabetic population. Higher risks were observed in women with insulin-treated GDM than those with diet-treated GDM. After limiting the analysis to term deliveries, an increased risk of perinatal mortality was observed. After excluding women suspected to have undiagnosed pregestational diabetes, the risk remained moderately increased only for those with diet-treated GDM (OR 1.3 [95% CI 1.0, 1.6]).Conclusions/interpretation: GDM is associated with a moderately increased risk of adverse perinatal outcomes, which is higher in insulin-treated GDM than in non-insulin-treated GDM for most outcomes

Perioperative management of adult diabetic patients. Preoperative period

Working party approved by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society for the study of Diabetes (SFD)International audienceIn diabetic patients undergoing surgery, we recommend assessing glycaemic control preoperatively by assessing glycated haemoglobin (HbA1c) levels and recent capillary blood sugar (glucose) levels, and to adjust any treatments accordingly before surgery, paying particular attention to specific complications of diabetes. Gastroparesis creates a risk of stasis and aspiration of gastric content at induction of anaesthesia requiring the use of a rapid sequence induction technique. Cardiac involvement can be divided into several types. Coronary disease is characterised by silent myocardial ischaemia, present in 30–50% of T2D patients. Diabetic cardiomyopathy is a real cause of heart failure. Finally, cardiac autonomic neuropathy (CAN), although rarely symptomatic, should be investigated because it causes an increased risk of cardiovascular events and a risk of sudden death. Several signs are suggestive of CAN, and confirmation calls for close perioperative surveillance. Chronic diabetic kidney disease (diabetic nephropathy) aggravates the risk of perioperative acute renal failure, and we recommend measurement of the glomerular filtration rate preoperatively. The final step of the consultation concerns the management of antidiabetic therapy. Preoperative glucose infusion is not necessary if the patient is not receiving insulin. Non-insulin drugs are not administered on the morning of the intervention except for metformin, which is not administered from the evening before. The insulins are injected at the usual dose the evening before. The insulin pump is maintained until the patient arrives in the surgical unit. It should be remembered that insulin deficiency in a T1D patient leads to ketoacidosis within a few hours

Perioperative management of adult diabetic patients. The role of the diabetologist

Working party approved by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society for the study of Diabetes (SFD)International audienceA patient should be referred to a diabetologist perioperatively in several circumstances: preoperative recognition of a previously unknown diabetes or detection of glycaemic imbalance (HbA1c 8%); during hospitalisation, recognition of a previously unknown diabetes, persisting glycaemic imbalance despite treatment or difficulty resuming previously used chronic treatment; postoperatively and after discharge from hospital, for all diabetic patients in whom HbA1c is > 8%

Pathologies maternelles chroniques et pertes de grossesse. Recommandations françaises

International audienceAim.-To review the available data on maternal chronic diseases and pregnancy losses.Material and Methods-We searched PubMed and the Cochrane library with pregnancy loss,stillbirth, intrauterine fetal demise, intrauterine fetal death, miscarriage and each maternaldiseases of this paper.Results-Antiphospholipid antibodies (anticardiolipin, anti-beta-2-glycoprotein, lupus anti-coagulant) should be measured in case of miscarriage after 10 WG confirmed by ultrasound(grade B) and an antiphospholipid syndrome should be treated by a combination of aspi-rin and low-molecular-weight heparin during a subsequent pregnancy (grade A). We donot recommend testing for genetic thrombophilia in case of first trimester miscarriage(grade B) or stillbirth (grade C). Glycemic control should be a goal before pregnancyfor women with pregestational diabetes to limit the risks of pregnancy loss (grade A)with a goal of prepregnancy HbA1c < 7%. Overt and subclinical hypothyroidisms should betreated by L-thyroxin during pregnancy to reduce the risks of pregnancy loss (grade A).Women who are positive for TPOAb should have TSH concentrations follow-up during pre-gnancy and subsequently treated by L-thyroxin if they develop subclinical hypothyroidism(grade B).Conclusions.-Prepregnancy management of most chronic maternal diseases, ideally throughprepregnancy multidisciplinary counseling, reduces the risks of pregnancy loss

Perioperative management of adult diabetic patients. Specific situations

Working party approved by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society for the study of Diabetes (SFD)International audienceAmbulatory surgery can be carried out in diabetic patients. By using a strict organisational and technical approach, the risk of glycaemic imbalance is minimised, allowing the patients to return to their previous way of life more quickly. Taking into account the context of ambulatory surgery, with a same day discharge, the aims are to minimise the changes to antidiabetic treatment, to maintain adequate blood sugar control and to resume oral feeding as quickly as possible. The preoperative evaluation is the same as for a hospitalised patient and recent glycaemic control (HbA1c) is necessary. Perioperative management and the administration of treatment depend on the number of meals missed. The patient can return home after taking up usual feeding and treatment again. Hospitalisation is necessary if significant glycaemic imbalance occurs. In pregnancy, it is necessary to distinguish between known pre-existing diabetes (T1D or T2D) and gestational diabetes, defined as glucose intolerance discovered during pregnancy. During labour, blood sugar levels should be maintained between 0.8 and 1.4 g/L (4.4–8.25 mmol/L). Control of blood sugar levels is obtained by using a continuous administration of insulin using an electronic syringe (IVES) together with a glucose infusion. Post-partum, management depends on the type of diabetes: in T1D and T2D patients a basal-bolus scheme is restarted with decreased doses while in gestational diabetes insulin therapy is stopped after delivery. Antidiabetic treatment is again necessary if blood sugar levels remain > 1.26 g/L (7 mmol/L)