Subclinical Cushing's syndrome (SCS) caused by adrenal incidentalomas is frequently associated with overweight and insulin resistance. Metabolic syndrome X may therefore be a clue to the presence of CS. However, the incidence of CS in this situation remains unknown. We have conducted a prospective study to evaluate the prevalence of occult CS in overweight, type-2 diabetic patients devoided of specific clinical symptoms of CS. Two hundred overweight, type-2 diabetic patients, consecutively referred for poor metabolic control (HbA(1C) > 8%), were studied as inpatients. A first screening step was performed with the 1-mg overnight dexamethasone suppression test (DST) using a revised criterion for cortisol suppression (60 nmol/liter) to maximize the sensitivity of the procedure. A second confirmatory step of biochemical investigations (midnight plasma cortisol concentration, plasma cortisol circadian rhythm, morning plasma ACTH concentration, 24-h urinary free cortisol, and 4-mg i.v. DST) was performed in patients with impaired 1-mg DST. A third step of imaging studies was performed according to the results of second-step investigations. Fifty-two patients had impaired 1-mg DST. Among these, 47 were further evaluated. Thirty were considered as false positives of the 1-mg DST, whereas 17 displayed at least one additional biological abnormality of the hypothalamic-pituitary-adrenal axis. Definitive occult CS was identified in four patients (2% of the whole series) with Cushing's disease (n = 3) and surgically proven adrenal adenoma (n = 1). Definitive diagnosis remains to be established in seven additional patients (3.5%) with mild occult CS associated with unsuppressed plasma ACTH concentrations and a unilateral adrenal tumor of 10-29 mm in size showing prevalent uptake at radiocholesterol scintigraphy. In conclusion, a relatively high prevalence of occult CS was found in our study. Further studies are needed to evaluate the impact of the cure of occult CS on obesity and diabetes mellitus in these patients. Such studies might provide a rationale for systematic screening of occult CS in this population.

Background and objectivesThe Opal Coast REDIAB healthcare network was created in 2001 after the implementation of a therapeutic patient education (TPE) programme for patients with type 2 diabetes by general practitioners (GPs) and nurses. The objectives of the network are: (i) to improve the quality of life of diabetic patients through TPE, the provision of support with regard to physical activity, diet, and psychological well-being, and improved care (annual monitoring, drug treatment), (ii) to work as a multi-professional team sharing a common personal patient files (DPP) over the internet.ProgrammeThe network comprises 118 general practitioners, 74 state-registered nurses, 58 podiatrists, four dieticians, and three physical activity trainers. It manages 1600 patients. The programme includes: Training of caregiversEducation of patients jointly by GPs and community nurses (course of six sessions)Support from a dieticianSupport for physical activityCounselling and group sessionsPrevention of foot wounds and amputations. An assessment was performed on a sample of 744 patients using glycated haemoglobin (HbA1c) as primary endpoint. According to the literature, HbA1c is a good intermediate predictor of complications and health costs. Secondary criteria were: HDL cholesterol, LDL cholesterl, triglycerides, weight, and quality of life. The Diabetes Health Profile (DHP-1) with its three subscales was used (BA: barriers to activity—PD: Psychological distress—DE: Disinhibited Eating).Results in 2007HbA1c decreased from 7.7627 to 7.3462% over 3 years. This decrease of –0.4165% (CI 0.29071 to 0.54225) was significant for a risk threshold of 0.05. It should be compared to the normal course of the disease calculated in the UKPDS study for conventional or intensive care which is an increase in HbA1c over 3 years. The improvement in HbA1c was greater the longer the patient had been a member of the network (p=0.05). This was the main factor in the improvement in HbA1c (there was a threshold effect after 4½ years), as if the ‘REDIAB effect’ grew in importance with time. The second factor explaining the improvement in HbA1c was insulin which had a statistically negative effect. Patients with diabetes without insulin presented a greater reduction in HbA1c than patients on insulin (p=0.01). The explanation for this, however, is not clear. Were these more difficult and complicated cases of diabetes?The third factor was DE in the DHP-1 questionnaire (p=0.05). Weight gain was not significant over 3 years unlike in the UKPDS study population (2–3.75 kg). There was a significant decrease (in g/l) in total cholesterol (–0.14), LDL cholesterol (–0.10) and triglycerides (–0.7).ConclusionThe strategy of the Opal Coast REDIAB network is effective as it offers extra support not available with conventional care. It promotes teamwork as well as training in better care by community and hospital caregivers and improves care pathways in which the GP holds a pivotal role. Working with GPs and community health professionals is a prerequisite for succ...