Gestational diabetes and adiposity are independent risk factors for perinatal outcomes: a population based cohort study in Sweden

AIMS

To evaluate the interaction effects of gestational diabetes (GDM) with obesity on perinatal outcomes.

METHODS

A population-based cohort study in Sweden excluding women without pre-gestational diabetes with a singleton birth between 1998 and 2012. Logistic regression was performed to evaluate the potential independent associations of GDM and BMI with adverse perinatal outcomes as well as their interactions. Main outcome measures were malformations, stillbirths, perinatal mortality, low Apgar score, fetal distress, prematurity and Erb's palsy.

RESULTS

Some 1,294,006 women were included, with a GDM prevalence of 1% (n = 14,833). The rate of overweight/obesity was 67.7% in the GDM-group and 36.1% in the non-GDM-group. No significant interaction existed. Offspring of women with GDM had significantly increased risk of malformations, adjusted odds ratio (aOR) 1.16 (95% confidence intervals 1.06-1.26), prematurity, aOR 1.86 (1.76-1. 98), low Apgar score, aOR 1.36 (1.10-1.70), fetal distress, aOR 1.09 (1.02-1.16) and Erb's palsy aOR 2.26 (1.79-2.86). No risk for stillbirth or perinatal mortality was seen. Offspring of overweight (BMI 25-29.9 kg/m² ), obese (BMI 30-34.9 kg/m² ) and severely obese women (BMI ≥ 35.0 kg/m² ) had significantly increased risks of all outcomes including stillbirth 1.51 (1.40-1.62) to 2.85 (2.52-3.22) and perinatal mortality 1.49 (1.40-1.59) to 2.83 (2.54-3.15).

CONCLUSIONS

There is no interaction effect between GDM and BMI for the studied outcomes. Higher BMI and GDM are major independent risk factors for most serious adverse perinatal outcomes. More effective pre-pregnancy and antenatal interventions are required to prevent serious adverse pregnancy outcomes among women with either GDM or high BMI.

Performance analysis of an orbital angular momentum multiplexed amplify-and-forward radio relay chain with inter-modal crosstalk

The end-to-end spectral efficiency and bit error rate (BER) of an amplify-and-forward (AF) radio relay chain employing orbital angular momentum (OAM) multiplexing is presented. The inherent divergence of a beam carrying OAM is overcome by means of a lens. Modelled and measured inter-modal crosstalk levels are incorporated into the analysis. The results show that an end-to-end spectral efficiency of up to 8 bits s^-1 Hz^-1 is achievable using four OAM modes to multiplex four parallel data streams over 20 hops, provided that the detrimental effects of inter-modal crosstalk are mitigated. The spectral efficiency is expected to scale further by using more OAM modes. The BER profile along the relay chain is analysed for each of the four OAM modes.

Impact of peer support on inpatient and outpatient payments among people with Type 2 diabetes: a prospective cohort study

AIM

To investigate the impact of a low-cost diabetes peer-support intervention, aimed at reducing inpatient and outpatient care utilization and healthcare payments, by conducting a cohort study that followed up a randomized controlled trial.

METHODS

A total of 1121 adults with Type 2 diabetes were recruited through general practices in Cambridgeshire and Hertfordshire, UK, and were followed up for 3.25 financial years after 8-12 months of one-to-one, group or combined diabetes peer support and usual care. Use of, and payments for inpatient and outpatient services were fully recorded in the follow-up. Adjusted mean inpatient and outpatient payments per person were estimated using a two-part model after adjusting for baseline characteristics.

RESULTS

The mean age of the recruited adults was 65.6±11.4 years, 60.4% were male, and 16.8% were insulin-treated. Compared with the control group, less healthcare utilization (especially non-elective inpatient care and outpatient consultations) was observed in each of the intervention groups, particularly the combined intervention group. Over the course of 3.25 financial years, significant reductions of 41% (£909.20 per head) were observed for overall inpatient payments (P<0.0001), 51% (£514.67 per head) for non-elective inpatient payments (P=0.005) in the combined intervention group, and 34% (£413.30 per head) and 32% (£388.99 per head) for elective inpatient payments in the one-to-one (P=0.029) and combined intervention (P=0.048) groups, respectively.

CONCLUSIONS

Type 2 diabetes peer support, whether delivered using a one-to-one, group or combined approach was associated with reduced inpatient care utilization (particularly non-elective admissions) and payments over 3.25 years.

Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings

BACKGROUND

In early 2016 the Partnership for Health IT Patient Safety released safe practice recommendations for the use of copy-paste for electronic health record (EHR) documentation. These recommendations do not directly address nurses' use of copy-forward to document patient assessments in flow sheet software in hospital settings. Similar to clinicians' use of copy-paste and copy-forward with progress notes, concerns exist about patient safety issues from the use of potential inaccurate or outdated information to achieve increased efficiency of documentation.

METHODS

A multiple-methods approach-which included a literature review, litigation search, stakeholder analysis, and consensus opinion from experts from multiple disciplines-was employed.

RESULTS

Four recommendations correspond closely with copy-paste guidance for EHR documentation from the Partnership: (1) Provide a mechanism to make copied-forward content easily identifiable, (2) Ensure that the provenance of copied-forward content is readily available, (3) Ensure adequate staff training and education regarding the appropriate and safe use of copy-forward in flow sheet software, if available, and (4) Ensure that copy-forward practices are regularly monitored, measured, and assessed. A fifth additional recommendation is made to improve the efficiency of data entry mechanisms, which may reduce patient safety risk. Emerging promising areas for innovation are to optimize interface usability and flow sheet content, use templates, use digital photographs, and eliminate work-flow steps with better methods for authentication and data entry.

CONCLUSIONS

A thoughtful and measured approach to safe use of copy-forward in flow sheets by nurses in hospital settings is expected to result in improvements in efficiency of documentation, work flow, and accuracy of information.

rs9939609 FTO genotype associations with FTO methylation level influences body mass and telomere length in an Australian rural population

BACKGROUND

The fat mass- and obesity-associated (FTO) gene influences energy homeostasis in humans. Although the obesity-related variant, rs9939609 has been replicated across a number of cohort studies, there remains significant variance and a low to modest association. Telomere length is another commonly reported obesity risk factor. We hypothesize understanding the associations between FTO rs9939609 with FTO methylation and telomere length will provide a more accurate assessment of obesity risk.

METHODS

Overall, 942 participants free of diabetes or pre-diabetes were included in the retrospective study. Leukocyte genomic DNA was analyzed for rs9939609 genotyping, FTO gene methylation and leukocyte telomere length (LTL) measurement.

RESULTS

In general linear models, rs9939609 AA genotypes were associated with increased fat percentage (3.15%, P=0.001), fat mass (4.16 kg, P=0.001), body mass index (BMI) (1.38, P=0.006) and waist circumference (3.35 cm, P=0.006), but not with FTO methylation or LTL in this overall population. However, when participants were stratified into higher and lower FTO methylation groups, the AA genotype possesses a 2.04-fold increased obesity risk in comparison to TT genotype (95%CI, 1.07-3.89, P=0.031) in participants with a higher FTO methylation level, but this association was absent in the lower FTO methylation sub-group. Moreover, AT and AA genotype carriers were associated with shorter LTL compared to TT carriers (P=0.020 and P=0.111, respectively) in the higher FTO methylation level group. However, this association was absent in the lower methylation group. Furthermore, FTO gene methylation level was significantly associated with LTL in the 942 samples (P=0.017).

CONCLUSIONS

FTO rs9939609 is associated with obesity risk and LTL in this study, where this association is only observed at higher, but not lower, FTO methylation levels of participants. Our data suggest association of multiple factors, including FTO methylation level, may be involved in one of several mechanisms underlying the commonly reported obesity risk of this FTO polymorphism.

Family Adjustment When the Breadwinner is Burned

Special consideration must be given to financial, legal and social welfare aspects of families where the breadwinner is burned. Some approaches to nursing assessment and intervention with families facing economic stress in addition to predictable emotional demands occurring with severe burns are elaborated through case illustration.

IFPA meeting 2015 workshop report I: placental mitochondrial function, transport systems and epigenetics

Workshops are an important part of the IFPA annual meeting as they allow for discussion of specialized topics. At IFPA meeting 2015 there were twelve themed workshops, three of which are summarized in this report. These workshops covered areas of placental regulation and nutrient handling: 1) placental epigenetics; 2) placental mitochondrial function; 3) placental transport systems.

Effectiveness of a multidisciplinary team approach to the prevention of readmission for acute glycaemic events

AIMS

To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes.

METHODS

Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods.

RESULTS

Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ±sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 (P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 (P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days (P = 0.003) per patient/month) across the three periods, as did the mean ±sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)].

CONCLUSIONS

The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach.

Prevention of gestational diabetes mellitus: Where are we now?

Gestational diabetes mellitus (GDM) is increasing at a rapid rate, driven by the increasing proportion of the population that is overweight/obese from a young age. More than 25 randomized controlled trials testing whether GDM can be prevented have now reported their findings, but only four different interventions have shown a reduction in the proportion of women with GDM (healthy eating alone, healthy eating with physical activity, myoinositol supplementation and probiotic treatment), and these results have not been replicated. The interventions tested to date include different diets and different forms of physical activity, in combination or alone, vitamin D, myoinositol, probiotics and metformin. Studies could be improved by using the International Association of Diabetes and Pregnancy Study Group criteria for GDM (which are probably more sensitive to change because of their multiple time points), targeting and tailoring interventions to subgroups most likely to benefit, and separating those with GDM early in pregnancy from those developing GDM de novo. The greatest societal benefit is likely to arise from population-based lifestyle approaches which include those women yet to become pregnant and those who are already pregnant and their families; an approach that is yet to be fully tested.

Association between pulse pressure and risk of hospital admissions for cardiovascular events among people with Type 2 diabetes: a population-based case-control study

AIM

To investigate the association between pulse pressure and risk of hospitalization for cardiovascular events among people with Type 2 diabetes.

METHODS

A population-based case-control study was carried out using data from medical databases. A total of 588 people with Type 2 diabetes from 18 general practices in Cambridgeshire recorded a first hospitalization for a cardiovascular event between 2009 and 2011, and a total of 2920 age-matched, gender-matched and practice-matched control subjects with Type 2 diabetes were selected based on risk-set sampling. Pulse pressure was assessed before admission in 2008-2009. Further dose-response relationships between pulse pressure and risks were explored using spline models.

RESULTS

There was a non-linear relationship between pulse pressure and the risk of hospitalization for a cardiovascular event (P < 0.001 for linearity test). The pulse pressure associated with the lowest risk of hospitalization for a cardiovascular event was 61 (95% CI 57-63) mmHg.

CONCLUSION

In people with Type 2 diabetes, pulse pressure is a good predictor of risk of hospitalization for cardiovascular events. The risk is lowest with a pulse pressure of 57-63 mmHg.

The metabolic syndrome and cancer: Is the metabolic syndrome useful for predicting cancer risk above and beyond its individual components?

AIMS

The metabolic syndrome (MetS) is a risk factor for cancer. However, it is not known if the MetS confers a greater cancer risk than the sum of its individual components, which components drive the association, or if the MetS predicts future cancer risk.

MATERIALS AND METHODS

We linked 20,648 participants from the Australian and New Zealand Diabetes and Cancer Collaboration with complete data on the MetS to national cancer registries and used Cox proportional hazards models to estimate associations of the MetS, the number of positive MetS components, and each of the five MetS components separately with the risk for overall, colorectal, prostate and breast cancer. Hazard ratios (HR) and 95% confidence intervals (95%CI) are reported. We assessed predictive ability of the MetS using Harrell's c-statistic.

RESULTS

The MetS was inversely associated with prostate cancer (HR 0.85; 95% CI 0.72-0.99). We found no evidence of an association between the MetS overall, colorectal and breast cancers. For those with five positive MetS components the HR was 1.12 (1.02-1.48) and 2.07 (1.26-3.39) for overall, and colorectal cancer, respectively, compared with those with zero positive MetS components. Greater waist circumference (WC) (1.38; 1.13-1.70) and elevated blood pressure (1.29; 1.01-1.64) were associated with colorectal cancer. Elevated WC and triglycerides were (inversely) associated with prostate cancer. MetS models were only poor to moderate discriminators for all cancer outcomes.

CONCLUSIONS

We show that the MetS is (inversely) associated with prostate cancer, but is not associated with overall, colorectal or breast cancer. Although, persons with five positive components of the MetS are at a 1.2 and 2.1 increased risk for overall and colorectal cancer, respectively, and these associations appear to be driven, largely, by elevated WC and BP. We also demonstrate that the MetS is only a moderate discriminator of cancer risk.

Diabetes UK Position Statement. Competency frameworks in diabetes

The quality, skills and attitudes of staff working in the healthcare system are central to multidisciplinary learning and working, and to the delivery of the quality of care patients expect. Patients want to know that the staff supporting them have the right knowledge and attitudes to work in partnership, particularly for conditions such as diabetes where 95% of all care is delivered by the person with diabetes themselves. With the current changes in the NHS structures in England, and the potential for greater variation in the types of 'qualified provider', along with the recent scandal at Mid-Staffordshire Hospital, staff need to be shown to be competent and named/accredited or recognized as such. This will help to restore faith in an increasingly devolved delivery structure. The education and validation of competency needs to be consistently delivered and assured to ensure standards are maintained for different roles and disciplines across each UK nation. Diabetes UK recommends that all NHS organizations prioritize healthcare professional education, training and competency through the implementation of a National Diabetes Competency Framework and the phased approach to delivery to address this need.

The effect of strict infection control policies on the rate of infection after elective foot and ankle surgery

The rate of surgical site infection after elective foot and ankle surgery is higher than that after other elective orthopaedic procedures.

Since December 2005, we have prospectively collected data on the rate of post-operative infection for 1737 patients who have undergone elective foot and ankle surgery. In March 2008, additional infection control policies, focused on surgical and environmental risk factors, were introduced in our department.

We saw a 50% reduction in the rate of surgical site infection after the introduction of these measures. We are, however, aware that the observed decrease may not be entirely attributable to these measures alone given the number of factors that predispose to post-operative wound infection.

Cite this article: Bone Joint J 2015;97-B:516–19.

Interpretation of HbA1c : association with mean cell volume and haemoglobin concentration

AIM

The utility of HbA1c in diabetes diagnosis is reduced in settings associated with altered haemoglobin glycation. We have studied whether HbA1c varies with mean cell volume and mean cell haemoglobin concentration as measures of haemoglobin metabolism.

METHODS

Randomly selected adults from rural Victoria, Australia, were invited for biomedical assessment. After excluding patients with known diabetes and/or serum creatinine ≥ 0.12 mmol/l, 1315 adults were included. Demography, arthropometric measurements, oral glucose tolerance test, analyses of full blood count and HbA1c were undertaken.

RESULTS

After adjusting for age, sex, ethnicity, BMI, town and socio-economic status, there were no significant differences in haemoglobin, mean cell volume or mean cell haemoglobin concentration by glycaemic status (defined by oral glucose tolerance test). HbA1c was significantly and independently associated with fasting glucose, town, mean cell haemoglobin concentration, ethnicity, age and BMI among men < 50 years (R² = 33.8%); fasting glucose, 2-h glucose, mean cell haemoglobin concentration and town among men ≥ 50 years (R² = 47.9%); fasting glucose, mean cell volume, mean cell haemoglobin concentration, town, 2-h glucose and age among women < 50 years (R² = 46.3%); fasting glucose, mean cell haemoglobin concentration, mean cell volume and 2-h glucose among women ≥ 50 years (R² = 51.6%). A generalized linear model showed a gradient from an adjusted mean HbA1c of 36 (95% CI 34-38) mmol/mol with a mean cell haemoglobin concentration of ≤ 320 g/l to 30 (95% CI 29-31) mmol/mol with a mean cell haemoglobin concentration of > 370 g/l. The gradient across mean cell volume was negative, but only by 1 mmol/mol (0.1%) HbA1c .

CONCLUSION

A mean HbA1c difference of 5 mmol/mol (0.5%) across the mean cell haemoglobin concentration reference range suggests that an accompanying full blood count examination may be required for its use in the diagnosis of diabetes. Further studies are required to confirm this.

Integrating Electronic Health Records into Clinical Workflow

Issues with workflow integration have contributed to slow rates of EHR adoption in ambulatory outpatient care settings. In response to workflow integration challenges with EHRs, clinicians often develop workarounds to complete clinical tasks in ways other than were intended by system designers. Based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created process map visualizations. A wide range of opportunities to improve workflow through enhanced functionality with the EHR were identified. Targeted recommendations for EHR developers and ambulatory (outpatient) care centers are proposed to increase efficiency, allow for better eye contact between the physician and patient, improve physician’s information workflow, and reduce alert fatigue. These recommendations provide a first step in moving from a billing-centered perspective to a clinician-centered perspective.

Association between lung capacity measurements and abnormal glucose metabolism: findings from the Crossroads study

AIM

To examine the association between lung function and metabolic syndrome/Type 2 diabetes.

METHODS

A total of 1454 adults from rural Victoria, Australia, from randomly selected households included in the Crossroads study, provided spirometric measurements including forced vital capacity, forced expiratory volume in 1 s, predicted percentage value of forced expiratory volume in 1 s and forced vital capacity predicted percentage value. Assessments also included HbA(1c), metabolic syndrome components and a 75-g oral glucose tolerance test. The area under the receiver-operating characteristic curves for waist circumference were compared with those for combinations of waist circumference and raw spirometric measures (forced vital capacity and forced expiratory volume in 1 s) for identifying metabolic syndrome or Type 2 diabetes.

RESULTS

Partipants with a greater number of metabolic syndrome components were more likely to have reduced lung function, particularly if Type 2 diabetes was present: the predicted value of forced expiratory volume in 1 s decreased by 5-6% for participants with 2-4 metabolic syndrome components, and by 9% for those with Type 2 diabetes. The risk of metabolic syndrome or Type 2 diabetes was inversely associated with higher spirometry values (forced expiratory volume in 1 s percentage predicted value: odds ratio for 2-4 metabolic syndrome components 0.36-0.21 in women and 0.32-0.30 men; the odds ratio for Type 2 diabetes was 0.36 in women and 0.28 in men). Receiver-operating characteristic curve analysis for identifying metabolic syndrome and Type 2 diabetes revealed significant differences between the area under the receiver-operating characteristic curve with waist circumference alone and that for the combination of waist circumference with lung capacity measures.

CONCLUSION

Pulmonary function is lower in people with metabolic syndrome and Type 2 diabetes. Spirometry variables are independent predictors of metabolic syndrome and Type 2 diabetes.

Relationship between HbA1c and risk of all-cause hospital admissions among people with Type 2 diabetes

AIM

To investigate the relationship between HbA(1c) and the 2-year risk of hospitalization among people with Type 2 diabetes.

METHODS

In total, 4704 patients from 18 general practices in Cambridgeshire were included. Glycaemic exposure was assessed in 2008-2009. The primary outcome was all-cause hospital admissions in 2010-2011. Adjusted relative risks for each HbA(1c) quintile were estimated using Cox models. Further relationships between HbA(1c) and risks were explored using spline models.

RESULTS

There was a non-linear relationship between HbA(1c) and the risk of all-cause, diabetes and vascular admissions (all P < 0.001 for linearity test) with an HbA(1c) threshold of 61 (95% CI 55-66) mmol/mol [7.7 (95% CI 7.2-8.2)%]. For every 11 mmol/mol (1%) HbA(1c) above the threshold, the risks increased by 6.3% for all-cause admission, 6.4% for a diabetes admission and 15.9% for a cardiovascular admission (all P < 0.001). The overall hospitalization risks of having an HbA(1c) above, rather than at, the threshold, were 19.1 16.3 and 54.3% greater, respectively. There were non-significantly greater risks of hospital admission below the threshold.

CONCLUSION

In people with Type 2 diabetes, a non-linear relationship exists between HbA(1c) and the risk of hospitalization. A threshold of 61 mmol/mol (7.7%) was associated with the lowest rate of all-cause hospital admissions. Further research should investigate the causes of admissions below and above this threshold, with a view to developing strategies to reduce the excess hospitalization among patients with diabetes.

Hypothalamic distribution of somatostatin mRNA expressing neurones relative to pubertal and adult changes in pulsatile growth hormone secretion in mice

The age-associated decline in growth hormone (GH) secretion may be a consequence of the reduction in the number of GH-releasing hormone (GHRH) positive neurones. However, it remains unclear whether an alteration in the number or distribution of somatostatin (SST) neurones contributes to this change. In the present study, we characterised the role of SST in modulating the change in pulsatile GH secretion in male C57Bl/6J mice throughout puberty and into early adulthood. We assessed pulsatile GH secretion in mice at 4, 8 and 16 weeks of age. These ages correspond to early pubertal, early adulthood and adulthood, respectively. We show an elevation in peak, total and pulsatile GH secretion coinciding with periods of rapid linear growth. Using in situ hybridisation and morphometric methods, we mapped the distribution of Sst mRNA expression within the mouse brain relative to this change in pulsatile GH secretion. The results obtained show that altered pulsatile GH secretion in male mice from 4-16 weeks of age does not coincide with a significant change in the number of Sst mRNA expressing neurones or an abundance of Sst mRNA expression throughout the arcuate nucleus (ARC) and periventricular nucleus (PeV). Rather, we observed a progressive decline in Sst mRNA expressing neurones within subnuclei of the paraventricular nucleus at this time. We conclude that structural changes in Sst expression within the PeV and ARC may not reflect the observed decline in pulsatile GH secretion in mice from puberty into early adulthood.

Plasma C-peptide concentration in women with Type 1 diabetes during early and late pregnancy

AIMS

There are previous suggestions of increased C-peptide concentration in women with Type 1 diabetes during pregnancy. Our aim was to re-evaluate the hypothesis of a pregnancy-induced increase by measuring plasma C-peptide concentration in women with stable blood glucose control under standardized fasting and meal-stimulated conditions.

METHODS

Ten women with Type 1 diabetes; median age 31.1 years, median diabetes duration 19 years, median HbA(1c) 52 mmol/mol (6.9%) were admitted to a clinical research facility for two 24-h visits in early (12-16 weeks) and late (28-32 weeks) pregnancy. Women They ate standardized study meals - 80-g carbohydrate dinner, 60-g carbohydrate breakfast, and fasted between meals and overnight. Closed-loop insulin delivery maintained stable and comparable glycaemic conditions. Paired samples for plasma glucose and C-peptide were obtained.

RESULTS

Plasma glucose levels were comparable in early (median 6.5 mmol/l; interquartile range 5.6-8.6) and late pregnancy (median 7.0 mmol/l; interquartile range 6.1-7.8; P = 0.72). There was no change in fasting or meal-stimulated plasma C-peptide concentration from early to late pregnancy; mean difference 4.0 pmol/l (95% CI -6.0 to 7.0; P = 0.9). Four women had detectable C-peptide; peak (range) early vs. late pregnancy 48.5 (10-115) vs. 40.0 pmol/l (80-105); P = 0.5, which was weakly associated with plasma glucose; R(2) = 0.15, P < 0.0001.

CONCLUSIONS

We found no gestational changes in plasma C-peptide concentration. Previously reported increases may reflect differences in glucose control and/or exogenous insulin doses. This study highlights the importance and challenges of standardizing experimental conditions for accurate plasma C-peptide measurement during Type 1 diabetes pregnancy.

Does a diabetes annual review make a difference?

AIMS

To determine whether a diabetes annual review, independently of other care processes, is followed by improved patient clinical measurements.

METHODS

Audits conducted independently of the diabetes annual review were analysed for a time-trend in patient clinical measures. An interaction variable between the review and the year of audit was used to test for a change in gradient before and after a diabetes annual review. Each patient formed their own control.

RESULTS

The data included 9471 audits on 3397 patients from 92 practices, and diabetes annual reviews from 2003 to mid-2008. Percentages of patients with raised HbA(1c) , systolic blood pressure and lipids improved from first to last audit. Predicted means after a diabetes annual review for HbA(1c) decreased by 0.13% (1.0 mmol/mol), for HDL cholesterol increased by 0.04 mmol/L and for triglyceride decreased by 0.2 mmol/L. Predicted systolic and diastolic blood pressure, total cholesterol and urinary albumin:creatinine ratio did not change significantly.

CONCLUSIONS

Metabolic control improved over time but this was largely independently of the diabetes annual review, which appears to add little clinical value to existing New Zealand general practice care processes. Currently, general practitioners are paid to undertake a diabetes annual review and report the measurements collected. We would argue that payment needs to be directed to demonstrating appropriate changes in clinical management or achieving meaningful clinical goals, and that the annual review results should be part of systematic feedback to general practitioners, particularly directed at clinical inertia.

Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review

BACKGROUND

Gestational diabetes mellitus is a potentially serious condition that affects many pregnancies and its prevalence is increasing. Evidence suggests early detection and treatment improves outcomes, but this is hampered by continued disagreement and inconsistency regarding many aspects of its diagnosis.

METHODS

The Vitamin D and Lifestyle Intervention for Gestational Diabetes Mellitus Prevention (DALI) research programme aims to promote pan-European standards in the detection and diagnosis of gestational diabetes and to develop effective preventive interventions. To provide an overview of the context within which the programme will be conducted and its findings interpreted, systematic searching and narrative synthesis have been used to identify and review the best available European evidence relating to the prevalence of gestational diabetes, current screening practices and barriers to screening.

RESULTS

Prevalence is most often reported as 2-6% of pregnancies. Prevalence may be lower towards the Northern Atlantic seaboard of Europe and higher in the Southern Mediterranean seaboard. Screening practice and policy is inconsistent across Europe, hampered by lack of consensus on testing methods, diagnostic glycaemic thresholds and the value of routine screening. Poor clinician awareness of gestational diabetes, its diagnosis and local clinical guidelines further undermine detection of gestational diabetes.

CONCLUSIONS

Europe-wide agreement on screening approaches and diagnostic standards for gestational diabetes could lead to better detection and treatment, improved outcomes for women and children and a strengthened evidence base. There is an urgent need for well-designed research that can inform decisions on best practice in gestational diabetes mellitus screening and diagnosis.