Increasing incidence of abnormal glucose tolerance in women with prior abnormal glucose tolerance during pregnancy: DIAGEST 2 study

AIMS

Mild blood glucose abnormalities during pregnancy may be linked to later glucose tolerance abnormalities or diabetes mellitus. Our aim was to determine the prevalence of diabetes mellitus (DM), impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) 6.75 years after delivery in women with differential blood glucose status during pregnancy.

METHODS

We compared long-term outcomes among control women (n = 221), women with abnormal glucose tolerance during pregnancy (AGT; n = 322) and women with gestational diabetes (GDM; n = 466) who participated in DIAGEST 1. Women were recruited from 15 public maternity units in France. Clinical parameters could be determined in 155 control, 220 AGT and 338 GDM subjects. Rates of DM, IGT, IFG and 'Any Abnormality' were compared between the groups (American Diabetes Association criteria).

RESULTS

Adherence to follow-up was 70.7%. Rates of DM, IGT and IFG were respectively 0.9% DM, 2.1% IGT and 3.6% IFG in the control group; rates in the AGT group were 6.3%, 11.3% and 6.3%. In GDM women, the rates of DM, IGT and IFG were, respectively, 18.0%, 13.4% and 8.5%. Predictors for DM were previous GDM, medical history of hypertension, age at delivery > or = 33 years, family history of diabetes, fasting glucose during pregnancy > or = 5.5 mmol/l and the severity of hyperglycaemia during pregnancy defined by the number of abnormal blood glucose values fasting, 1, 2 and 3 h during the glucose tolerance test at diagnosis of GDM.

CONCLUSION

This study has identified a high prevalence of glucose tolerance abnormalities after AGT during pregnancy. Compared with GDM women, women with AGT have an intermediate risk of later diabetes.

[Fifteen practical questions concerning gestational diabetes]

With a review of the current literature, a clarification on screening and management of gestational diabetes is hereby set out, within the frame of a Clinical Expert Series. According to the ethnic group, the prevalence varies from 1 to 14%. The treatment is based on dietary advice, insulin. The ACHOIS study demonstrates that the treatment of gestational diabetes significantly decreases perinatal complications (4 to 1%). The place of the oral treatment (glyburide) remains to be defined. In most countries, diagnosis rests on oral glucose test tolerance: Sullivan 50 g glucose test (1 hour) and 100 g test of glucose if positive (3 hours); WHO 75 g test (2 hours). The screening can be systematic or only on risk factors (wide variations between studies). Screening of gestational diabetes is required because its management improves pregnancy outcomes. Despite this, there is no consensus on the strategy of screening and diagnosis.

[The metabolic syndrome: marker of cardiovascular risk in hypertensive patients? The importance of definition]

INTRODUCTION

Metabolic syndrome (MetS) was defined by association of abdominal obesity, hypertension, glucose intolerance and/or dyslipidemia. The objective of this study was to compare the new International Diabetes Federation (IDF) definition and the National Cholesterol Education Program Adult Treatment Panel III (NCEP) definition and their association with cardio-vascular disease in hypertensive patients.

POPULATION AND METHOD

Two hundred and thirty hypertensive patients were hospitalized successively for cardio-vascular disease exploration and hs-CRP measurement. The stratification of cardio-vascular risk was made according to the French recommendations. The IDF definition and the NCEP definition were compared according frequency of resistant hypertension and cardio-vascular disease extension.

RESULTS

In our study, high cardio-vascular risk hypertension represented 68.5% of patients. Diabetes was present in 23.5% of them and obesity in 45.5%. Patients with cardio-vascular disease represented 60% of our study population. Prevalence of MetS was 38.5% according to the NCEP definition and 59% according to the IDF definition. The NCEP definition was allowed to select subjects with widespread vascular disease and resistant hypertension whereas the IDF definition did not. These results could be explained by lower waist circumference and glycaemia cuts offs according to the IDF criteria. When diabetic's patients were excluded, MetS was not associated with increase of resistant hypertension frequency. Moreover, hs-CRP was independently associated to the extension of the cardiovascular disease and smoking remained the most powerfully factor associated to the cardio-vascular disease extension.

CONCLUSION

In hypertensive patients, the NCEP definition seems more adapted to the diagnosis of MetS than the IDF one. Abdominal obesity could be the indispensable element to the MetS diagnosis but according to the NCEP waist circumference cut off. The use of this syndrome seems to be relevant to select the patients presenting an intermediate cardio-vascular risk in order to adapt treatment.

No loss of genomic imprinting of IGF-II and H19 in placentas of diabetic pregnancies with fetal macrosomia

OBJECTIVES

Fetal macrosomia is a common complication of maternal diabetes mellitus and is associated with substantial morbidity, but the precise cellular and molecular mechanisms that induce fetal macrosomia are not well understood. The imprinted genes IGF-II and H19 are crucial for placental development and fetal growth. The term placentas from diabetic pregnancies express more insulin-like growth factor II (IGF-II) than those from normal pregnancies. Deregulation of their imprinting status is observed in the macrosomia-associated syndrome, the Beckwith-Wiedemann syndrome. The aim of this study was to determine whether loss of imprinting hence biallelic expression was also a hallmark of macrosomia in diabetic pregnancies.

DESIGN AND METHODS

IGF-II and H19 maternal and paternal expressions were studied in placentas from two groups of type 1 diabetic mothers: one with macrosomic babies and the other with babies of normal weight. Maternal or paternal allele specific expressions were defined by using DNA polymorphic markers of the IGF-II and H19 genes. RFLP analysis was performed on PCR products from genomic DNA of the father, the mother and the child, and on RT-PCR products from placental mRNA.

RESULTS

RFLP analysis showed that the IGF-II gene remains paternally expressed and the H19 gene remains maternally expressed in all placentas examined, independently of the birth weight status.

CONCLUSIONS

These results suggest that, in contrast with Beckwith-Wiedemann syndrome-associated macrosomia, loss of imprinting for IGF-II or H19 is not a common feature of diabetic pregnancies associated with macrosomia.

Diabetes mellitus and dementia

Alzheimer's disease (AD) and diabetes mellitus (DM) are two of the most common and devastating health problems in the elderly. They share a number of common features amongst which high prevalence after 65 years, important impact of patient's quality of life, substantial health care costs. Reviews on the epidemiological studies on cognitive impairment in patients with DM found evidence of cross-sectional and prospective associations between type 2 DM and moderate cognitive impairment, on memory and executive functions. There is also evidence for an elevated risk of both vascular dementia and AD in patients with type 2 DM, albeit with strong interaction of other factors such as hypertension, dyslipidaemia and ApoE genotype. DM is an independent predictor of post-stroke dementia. DM being an atherogenic risk factor, it may increase the risk of dementia through associations with stroke, causing vascular dementia. In addition, vascular reactivity may be adversely affected by advanced glycosylation end products resulting in more subtle perfusion abnormalities. Cerebrovascular disease may exacerbate AD through direct interactions between the two pathological processes or through cognitive impairment secondary to cerebrovascular disease "unmasking" AD at an earlier stage than it would otherwise become apparent. The increased risk of AD may also be mediated by the exacerbation of B-amyloid neurotoxicity by advanced glycosylation end products identified in the matrix of neurofibrillary tangles and amyloid plaques in AD brains, or associations with insulin functions. Decreased cholinergic transport across the blood-brain barrier observed in diabetic animals may exacerbate cognitive impairment in AD. Many interventions could reduce the cognitive decline associated with DM, yet not enough are taken into account so far.

Blood ketone monitoring: a comparison between gestational diabetes and non-diabetic pregnant women

AIM

To measure ketonemia in a control population of pregnant women and in a population of women with gestational diabetes (GDM). To define a normal ketonemia threshold for the controls and to determine whether or not this value could play a role in the clinical management of women with GDM.

METHOD

Fifty-six women with a normal OGTT and 49 women with GDM were included and monitored from the 25th to the 37th week of pregnancy. Control subjects agreed to perform glycaemia and ketonemia self-monitoring 3 times a day. In addition, women with GDM were asked to measure their postprandial glycaemia. Glycaemia and ketonemia measurements were performed using Optium meters. Subjects kept a 24-hour food record twice a week.

RESULTS

The mean ketonemia was lower in the control group than in the GDM group (0.01+/-0.10 vs. 0.04+/-0.009 mmol/l; P<0.001). Ketonemia values measured before the midday meal and prior to the evening meal were lower for control subjects than for GDM patients (P=0.002 and P=0.005). Fasting ketonemia was unrelated to ketonuria in the GDM group, whereas there was a correlation in the control group (P=0.006). At least one chronic increase in ketonemia levels was observed in 47% of the women with GDM, compared with only 12% of controls. The lowest levels of evening glycaemia correlated with the highest levels of ketonemia; women with GDM reported lower food and carbohydrate intakes than controls (P<0.001).

CONCLUSION

This work has enabled the establishment of ketonemia reference standards in non-diabetic pregnant women. If ketonemia does indeed indicate overly restrictive dietary behavior, this parameter could be employed for monitoring adherence to the nutritional recommendations for GDM.

pH-dependent kinetics of MgCl2 adsorption under a fatty-acid Langmuir film

The effect of subphase pH (5.5 and 10.5) on the structure of behenic-acid monolayers was investigated during Mg(2+) adsorption by means of Grazing Incidence X-ray Diffraction (GIXD) and Brewster Angle Microscopy (BAM). The final phase corresponding to an ion superlattice commensurate to the behenic-acid cell is pH-independent. In contrast, the sequence of phases evidenced from the initial L(2)-phase to this final state presents at pH 10.5 an additional stage associated to a film condensation toward the L' (2)-phase. The structures of the intermediate states preceding the superstructure nucleation are slightly different, both with a short-range fatty-acid order. Finally, a laser light effect that could result from visible light absorption by the inorganic complexes is evidenced in the final state as well as in the intermediate phases.

Influence of a neoglycolipid and its PEO-lipid moiety on the organization of phospholipid monolayers

The surface properties of the neoglycolipid (GlcNAcE(3)G(28)) and of its PEO-lipid (E(3)G(28)) moiety mixed with phospholipids (dipalmitoylphosphatidylcholine, DPPC; distearoylphosphatidylcholine, DSPC; diarachidoylphosphatidylcholine, DAPC; and dibehenoylphosphatidylcholine, DBPC) were studied in Langmuir monolayers at various mixture compositions and surface pressures. The pi-A isotherms of the pure compounds revealed that because of the presence of the sugar group in its molecule, GlcNAcE(3)G(28) collapsed at a higher surface pressure and occupied a larger molecular area than the PEO-lipid moiety. It was also observed that the presence of the PEO-lipid (E(3)G(28)) in the mixtures triggered a strong alteration of both phospholipid pi-A isotherm profiles and surface diffraction spectra, an indication that the disordering of the initially structured phospholipid monolayers took place. Unlike E(3)G(28), GlcNAcE(3)G(28) did not disorganize phospholipid monolayers but generated a partial segregation of the film-forming components. The calculated excess free energies of mixing (DeltaG(exc)) for GlcNAcE(3)G(28)-phospholipid mixtures enabled us to predict the stability of such systems.

Control of cardiovascular risk factors in patients with type 2 diabetes and hypertension in a French national study (Phenomen)

For some years now, the recommendations of scientific societies have significantly reduced the therapeutic targets for blood pressure, glycaemia and lipid levels in diabetic patients. However, little is known regarding the synchronization between effective risk factor management and the guidelines. To examine this issue, the Phenomen survey was conducted between January and July 2001 on 16358 patients suffering from hypertension followed by a general practitioner in France.

AIM

To evaluate the control of cardiovascular risk factors in patients with diabetes and hypertension according to the French guidelines.

METHODS AND PATIENTS

8177 general practitioners, selected from a national database according to quotas, taking into account age, practice and area, had to include the first two hypertensive patients they came across in their practice and to collect their demographic data, cardiovascular risk factors and medications.

RESULTS

2346 out of 16358 hypertensive patients presented with type 2 diabetes (14.3% of the cohort). The number of GP consultations in the last 12 months averaged 8.31. According to the French guidelines, 6.5% had a blood pressure<140/80 mmHg, a total of 38.7% patients met the goal of LDL cholesterol level and 26.6% of patients had an HbA1c<6.5%, 53.4% of patients had an HbA1c between 6.6 and 8%. 37.1% of patients continued to receive antihypertensive monotherapy but only 3% in this monotherapy group reached the target of 130/85 mmHg. 29% of the patients were on antiplatelet therapy. 64.6% of these hypertensive diabetic patients presented with more than three other cardiovascular risk factors. Based on WHO recommendations, 0.3% of the patients met all of the blood pressure, lipid and glycaemic treatment objectives.

CONCLUSION

Despite frequent monitoring by a general practitioner, the overall management of modifiable risk factors in this diabetic hypertensive population is clearly inadequate. The impact of the guidelines on effective management remains limited and additional information is required to understand why physicians are not more aggressive in managing modifiable risk factors in diabetic patients.

Comparison between Leukoscan® (Sulesomab) and Gallium-67 for the diagnosis of osteomyelitis in the diabetic foot

OBJECTIVES

The diagnosis of osteomyelitis in patients with diabetic foot is difficult both clinically and radiologically. An early diagnosis is crucial to optimize therapeutic strategy. Among the diagnostic methods currently used, scintigraphy with ex-vivo labelled white blood cells is the gold standard, but cannot be performed in all centers; therefore 67Gallium citrate (67Ga) imaging in combination with a bone scintigraphy is still widely used.

METHOD

The results of imaging 24 diabetic patients with 31 suspected osteomyelitic lesions using the antigranulocyte Fab' fragment (Sulesomab or LeukoScan or immunoscintigraphy) were prospectively compared with results from the bone scan coupled with 67Ga. The diagnosis of osteomyelitis was confirmed by either biopsy or follow-up, radiological imaging and clinical outcome.

RESULTS AND CONCLUSION

Sulesomab correctly identified 12 of 18 osteomyelitic lesions while 67Ga was able to detect only 8 of 18. Therefore the sensitivity is 67% for Sulesomab and 44% for 67Ga. Among the 13 non-osteomyelitic lesions imaging with Sulesomab was able to rule out infection in 11 cases and 67Ga in 10 cases. The specificity is therefore 85% for Sulesomab and 77% for 67Ga. Image interpretation for Sulesomab in this group of patients is occasionally suboptimal when imaging is performed at 3 hours post injection. High vascular background in the early images may obscure infection especially in small bones. Practically, scintigraphy with Sulesomab is fast and simple due to ease of labeling, no ex-vivo handling of blood, low radiation and provides rapid diagnosis. The diagnosis of osteomyelitis obtained by the antibody fragment scintigraphy influences the management (guided biopsy) and therapy. In several patients, imaging with Sulesomab was able to rule out osteomyelitis, helping to avoid useless antibiotic therapy and its associated side effects.

Polymorphisms of the Receptor of Advanced Glycation Endproducts (RAGE) and the development of nephropathy in type 1 diabetic patients

OBJECTIVES

We investigated the association of the RAGE (Receptor for Advanced Glycation End products) exon3 gene polymorphisms with stages of nephropathy in type 1 diabetes.

METHODS

The RAGE exon 3 genotype was assessed by Denaturing Gradient Gel Electrophoresis (DGGE) procedure in 487 type 1 diabetic patients with proliferative retinopathy subdivided into four groups according to their level of renal involvement and in 351 control subjects (GENEDIAB study).

RESULTS

We reported here three main low frequency dimorphisms, previously submitted to data banks, Gly82Ser, Val89 CTC/CTG, and Arg77Cys. The genotype distribution of these polymorphisms was not statistically different in type 1 diabetic patients compared to healthy controls (p=0.37). Among the three described polymorphisms, only the RAGE Gly82Ser genotype frequency was significantly increased in the group with advanced nephropathy (11%) defined by a chronic renal failure compared to the three others groups: no nephropathy, 5%; incipient (microalbuminuria) 5%; established (macroalbuminuria), 2%) (P=0.04). The 82 Ser allele was identified as an independent risk marker for the stage of advanced nephropathy: adjusted odds ratio 3.17(95% CI 1,32-7,85, p=0.008).

CONCLUSION

These data suggest that the 82 Ser allele of the RAGE gene is a risk allele for developing advanced nephropathy. This suggests that some RAGE gene polymorphisms may be associated with progression to diabetic advanced nephropathy in Caucasian type 1 diabetic patients.

Observation of a two-step mechanism in the formation of a superstructure of cadmium-behenic acid Langmuir monolayer: evidence of an intermediate structure

By means of grazing incidence x-ray diffraction, the structure of a behenic acid monolayer spread over chloride salt solutions of cadmium is observed to evolve from the tilted L2 phase to the superstructure (corresponding to an organized monolayer of ions in addition to the ordered organic film), through an intermediate phase. The studied salt concentrations are below the so-called "threshold" needed for the formation of this superstructure. This kinetic process involving two first-order phase transitions is confirmed by Brewster angle microscopy experiments and surface pressure-area isotherms measured at different times after monolayer deposition.

Insulin analogues (insulin detemir and insulin aspart) versus traditional human insulins (NPH insulin and regular human insulin) in basal-bolus therapy for patients with type 1 diabetes

AIMS/HYPOTHESIS

The aim of the trial was to compare the efficacy and tolerability of two types of basal-bolus therapy, using either the soluble long-acting basal insulin analogue, insulin detemir, in combination with the rapid-acting analogue, insulin aspart, or NPH insulin in combination with mealtime regular human insulin.

METHODS

In this 18-week, 1:1 randomised, open-labelled, parallel trial, 595 patients with Type 1 diabetes mellitus received insulin detemir or NPH insulin in the morning and at bedtime in combination with mealtime insulin aspart or regular human insulin respectively.

RESULTS

Glycaemic control with insulin detemir/insulin aspart was improved in comparison with NPH insulin/regular human insulin (HbA1c: 7.88% vs 8.11%; mean difference: -0.22% point [95% CI: -0.34 to -0.10]; p<0.001). Self-measured 8-point plasma glucose profiles differed between the groups (p<0.001), with lower postprandial plasma glucose levels in the insulin detemir/insulin aspart group. Within-person day-to-day variation in plasma glucose was lower with insulin detemir/insulin aspart than with NPH insulin/regular human insulin (SD: 2.88 vs 3.12 mmol/l; p<0.001). Risk of overall and nocturnal hypoglycaemia (23.00-06.00 hours) was, respectively, 21% (p=0.036) and 55% (p<0.001) lower in the insulin detemir/insulin aspart group than in the NPH insulin/regular human insulin group. Body weight (adjusted for baseline and change in HbA1c) was 1 kg lower with insulin detemir/insulin aspart than with NPH insulin/regular human insulin (p<0.001).

CONCLUSIONS/INTERPRETATION

Basal-bolus therapy using insulin detemir/insulin aspart offers a better balance of control and tolerability than with NPH insulin/regular human insulin. The low variability and more physiological action profiles generated with these insulin analogues resulted in improved glycaemic control with lower risk of hypoglycaemia and no concomitant body weight increase.

Self-monitoring of blood glucose significantly improves metabolic control in patients with type 2 diabetes mellitus: the Auto-Surveillance Intervention Active (ASIA) study

OBJECTIVE

Self monitoring of blood glucose (SMBG) in type 2 diabetes is a topic of current interest (imbalance between increased health-care costs and improvement in compliance with treatment and diet). An open label randomized prospective study was designed to compare changes in metabolic control over 6 months in patients managed with usual recommendations alone (conventional assessment group) or combined with SMBG.

RESEARCH DESIGN AND METHODS

Patients not treated with insulin or previously self monitored, 40 to 75 years of age, with a diagnosis of type 2 diabetes > 1 year and standardized HbA(1c) level > =7.5 and< =11% were randomized to either a control group or SMBG group. They were followed up every 6 weeks over 24 weeks. Patients in the SMBG group were given the same device (Ascensia Esprit Discmeter, Bayer) and were required to perform at least 6 capillary assays a week (3 different days of the week, including weekend). Management of patients was standardized, including drugs, diet and physical activity. The primary efficacy criterion was change in HbA(1c) level in Intent To Treat (ITT) patients. Assays were performed at baseline, at 3 and 6 months using the calibrated DCA 2000(R) device (Bayer).

RESULTS

Two hundred sixty five general practitioners randomized 988 patients (ITT Population), but 689 patients were evaluable for the primary criterion. At the endpoint, HbA(1c) was lower in the SMBG group (8.1 +/- 1.6%) than in the conventional treatment group (8.4 +/- 1.4%, P=0.012). The change in HbA(1c) levels between baseline and endpoint was classified into two classes: improvement if a change > 0.5% occurred, stability or worsening in case of a change< =0.5%; 57.1% of patients in the SMBG group vs 46.8% in the control group had an improvement in HbA(1c) level (P=0.007) after 3 months. A steady state was reached during the last 3 months. A multivariate logistic regression analysis was performed and identified factors predictive of improvement in HbA(1c) levels: HbA(1c) at baseline: odd ratio (OR)=1.749 (P<0.001), SMBG group (reference value: SMBG group): OR=0.665 (P=0.015), duration of diabetes: OR=0.953 (P=0.001) and BMI: OR=0.962 (P=0.039).

CONCLUSIONS

This study is the first multicenter, controlled, prospective trial conducted on a large number of patients demonstrating that SMBG was statistically associated with a better quality of metabolic control than usual traditional recommendations alone in type 2 diabetes.

[Is assessment of kidney involvement in patients with essential hypertension satisfactory? General medical observation results in a national study (PHENOMEN)]

According to ANAES guidelines (2000) adapted from the international guidelines, kidney function should be regularly monitored in hypertensive patients in order to detect vascular nephropathy at an early stage and prevent kidney failure which is a major cardiovascular factor. The PHENOMEN survey was conducted between January and July 2001 on a representative sample of 16,358 patients suffering from hypertension being followed by a General Practitioner (GP). The population included patients from all 22 administrative regions in France.

AIMS

To determine the prevalence of renal involvement in patients with hypertension (both treated and untreated); to compare the GP's subjective evaluation of the extent of renal involvement with a more objective assessment made according to ANAES guidelines.

METHODS

Kidney function was evaluated by measuring plasma creatinine levels to derive a value for the creatinine clearance rate (CCR) using the Cockeroft-Gault formula.

RESULTS

Out of the 16,358 patients included, plasma creatinine levels could be measured in 11,586 (76%) [53% men; 47% women, mean age = 63 +/- 12 years]: mean plasma creatinine = 90 +/- 49 mumol/l, i.e. a mean CCR of 83 +/- 32 ml/min. For 8,650 of the patients (75%), kidney function had been monitored in the preceding twelve months. The physicians defined their patient's kidney function as normal in 10,080 (87%) of cases whereas in reality, 4,411 of 8,650 (51%) were suffering from some degree of renal insufficiency (RI): in 2,422 (28%), RI was mild (> or = 60 CCR < 80 ml/min): in 1,903 (22%) RI was moderate (> or = 30 CCR < 60 ml/min). A minority of patients (44 i.e. 1%) showed severe RI (CCR < 30 ml/min).

CONCLUSION

Most GPs apply ANAES guidelines and order plasma creatinine assays. However, there is a discrepancy between how the physician "perceives" the seriousness of the renal insufficiency and a more objective measure based on the CCR figure. It would seem that the CCR derivative is insufficiently exploited despite the widespread availability of converters. Thus, the PHENOMEN survey has revealed that the extent of renal involvement in patients with hypertension still tends to be underestimated by GPs despite the major implications of this complication in terms of therapeutic strategy and global cardiovascular risk.

[Self-monitoring of blood glucose in gestational diabetes mellitus]

About 6% of all pregnancies are complicated by gestational diabetes mellitus in France. Consensus is obtained for defining but not for the screening and diagnosis criteria. Management of gestational diabetes mellitus reduce materno-foetal morbidity. Postprandial blood glucose peaks are highly predictive of macrosomia and have to be controlled in strict rates: less than 1.40 g/liter one hour after meal and less than 1.20 g/liter two hours after meal. Self-monitoring of blood glucose allows to start more rapidly insulintherapy, to obtain a better glycemic control and to reduce macrosomia. The impact of self-monitoring appears to be lower in the management of diet-controlled gestational diabetes. After delivery, self-monitoring of blood glucose can be used to control normalisation of blood glucose of women with high risk of type 2 diabetes mellitus.

[Maternal and fetal outcome]

Gestational diabetes, a glucose tolerance disorder of variable severity which occurs or is diagnosed for the first time during pregnancy, constitutes a public health problem because of its frequency (1 to 6% of all pregnancies) and its short-or long term consequences for the foetus and/or the mother. There is as yet still no consensus concerning screening and diagnosis criteria, therapeutic management and the reality of the disease. This population is a high risk population of diabetes mellitus, especially of type 2 diabetes. We could think that the introduction of specific prevention programs in this group could delay or avoid diabetes mellitus and its complications. The mechanisms which could explain gestational diabetes are the same as type 2 diabetes mellitus. We could speculate that these two diseases are identical for alterations in carbohydrate metabolism, but at different stages. It has been reported that the offspring of gestational diabetics mothers are at risk of obesity and glucose intolerance. Therapeutic management of the mother and/or the offspring should be better defined. The screening for gestational diabetes provides an opportunity of identify a large population of women and children at risk of diabetes. It should be possible to avoid diabetes mellitus by specific therapeutic programs in these populations.

[Pathophysiology of gestational diabetes]

During pregnancy, a number of maternal metabolic changes occur early and continue throughout pregnancy which help optimize the transfer of nutrients to the fetus. During normal pregnancy, there are a decrease in insulin sensibility which is physiological, progressive and reverse. For glucose tolerance to be maintained in pregnancy it is necessary for maternal insulin secretion to increase sufficiently to counteract the fall in insulin sensitivity. The metabolic characteristic of women with gestational diabetes is insufficient insulin secretion to counteract the pregnancy related fall in insulin sensitivity. There are a lot of factors that could explain the mechanism of insulin secretion and insulin sensitivity during normal pregnancy and gestational diabetes mellitus. Although glucose tolerance normalizes shortly after pregnancy with gestational diabetes in the majority of women, the risk of developing overt diabetes, especially type 2 diabetes is markedly increased. The mechanisms which could explain gestational diabetes are the same as type 2 diabetes mellitus. We could speculate that these two diseases are identical for alterations in carbohydrate metabolism, but at different stages.

Variation of the in-plane structure with depth revealed by grazing incidence x-ray diffraction in a thin Langmuir-Blodgett film

Grazing incidence x-ray diffraction is used to characterize the molecular arrangement of ultrathin Langmuir-Blodgett (LB) multilayers. Using two angles of incidence of the beam allowing its penetration either throughout the complete depth of the film or only through the external layers, we show that it is possible to discriminate between the molecular packing of the deeper monolayers and that of the external monolayers of the LB film.

CTLA-4 49 A/G dimorphism and type 1 diabetes susceptibility: a French case-control study and segregation analysis. Evidence of a maternal effect

Several studies have demonstrated an association of cytotoxic T lymphocyte-associated molecule 4 (CTLA-4) (IDDM 12) alanine 17 with type 1 diabetes, but we wished to study the parental effect of CTLA-4 49 A/G dimorphism in diabetic families. The CTLA-4 exon 1 polymorphism (49 A/G), HLA-DRB1 and insulin gene (INS) variable number tandem repeats (VNTR) were analysed in 134 type 1 diabetic patients vs. 273 control subjects. The segregation analysis for transmission was carried out in 70 informative diabetic families using the transmission distortion test (TDT). All genotyping was performed by PCR-RFLP. CTLA-4 49 G allele frequency was not increased in diabetic patients compared to controls (41 vs. 38%, not significant). The distribution of GG, AG and AA CTLA-4 genotypes was similar in the two groups (13, 57 and 30% vs. 11, 54 and 35%, respectively) and was independent of HLA-DRB1 or INS VNTR polymorphism. The CTLA-4 49 G allele showed weak distorted transmission to the diabetic offspring, whereas random transmission was observed in unaffected offspring. This distortion is attributable to a maternal effect (71% compared to the 50% expected ratio; tdt = 4.8; P < 0.03). The combined transmission of maternal CTLA-4 G with HLA-DRB1*03 (90%; tdt = 6.4; P < 0.01) and VNTR class I (80%; tdt = 5.4; P < 0.02) enhanced the susceptibility effect of each marker separately. We noted a slight CTLA-4 49 G and HLA-DRB1*04 distortion of transmission shared in paternal and maternal diabetic meiosis. In non-diabetic offspring, the CTLA-4 49 A allele confers a protective effect in the presence of maternal HLA-DRB1*03 and paternal HLA-DRB1*04 alleles. Despite the absence of a positive association of the CTLA-4 49 G allele with type 1 diabetes, our segregation analysis supports the hypothesis of a modulation by CTLA-4 49 G/A dimorphism of the susceptibility conferred by maternal HLA-DRB1*03 inheritance. This potential parental effect needs to be confirmed in a larger data set.

Pregnancy induced hypertension in women with gestational carbohydrate intolerance: the diagest study

OBJECTIVE

To determine the relationship between pregnancy induced hypertension (PIH) and gestational glucose intolerance.

METHODS

A 50g, 1h glucose loading test was offered to all pregnant women between 24 and 28 weeks of gestation in 15 centres in northern France during 8 months in 1992. If the test was positive (> or =7.2 mmol/l), the woman underwent a 3h oral glucose tolerance test (OGTT) as soon as possible. Using the criteria of Carpenter and Coustan, gestational diabetes mellitus (GDM) was defined by two abnormal values (n=218) and gestational mild hyperglycemia (GMH) by one abnormal value (n=130). Each control group was defined by a 50g, 1h loading test result of <7.2 mmol/l (n=108).PIH included gestational hypertension (GH) and preeclampsia (PE). GH was defined as a diastolic pressure of more than 85 mmHg on at least two occasions arising during pregnancy. PE was defined as GH with proteinuria > or =500 mg/24h.

RESULTS

The rate of PIH in the three groups (GDM; GMH and control group, C) was, respectively 17.0, 10.8, and 4.6%. All the six PE occurred in the GDM group. Univariate analysis showed significantly higher rate of hypertension in women with a history of PE, increasing body mass index before pregnancy (BMI) and glucose intolerance. In multivariate analysis with adjustment for primiparity, independent risk factors for PIH were a history of PE, BMI>27 and GDM, contrary to GMH and maternal age.

CONCLUSIONS

PIH appears to be linked to the level of glucose intolerance during pregnancy, independently of other known factors of hypertension.