A review of interventions to prevent Type 2 Diabetes after Gestational Diabetes

BACKGROUND

Gestational Diabetes Mellitus (GDM) during pregnancy is a risk factor for the development of Type 2 Diabetes (T2DM) within 15 years, and prevention programmes have been problematic.

QUESTION

The aim of the study is to identify effective strategies and programmes to decrease the risk of T2DM in women who experience GDM, the barriers to participation, and the opportunities for midwives to assist women in prevention.

METHODS

English language, peer reviewed and professional literature published between 1998 and 2013 were searched. A systematic review of the literature was undertaken, included studies were then appraised for quality and finally findings of the studies were thematically analysed.

FINDINGS

This review identified that there are interventions that are effective, however most lifestyle changes are difficult to translate into everyday life. As the incidence of GDM is expected to rise, midwives' role in promoting long-term health behaviours requires further review.

CONCLUSIONS

Women need to overcome barriers and be supported in making the behavioural changes necessary to prevent T2DM following GDM. Midwives as the primary carers for women in pregnancy and childbirth are ideally positioned to educate women and engage them in lifestyle and behaviour programmes that prevent the onset of Type 2 Diabetes.

Diffusion-weighted imaging and magnetic resonance proton spectroscopy following preterm birth

AIM

To study the associations between magnetic resonance proton spectroscopy (MRS) data and apparent diffusion coefficients (ADC) from the preterm brain with developmental outcome at 18 months corrected age and clinical variables.

MATERIALS AND METHODS

A prospective observational cohort study of 67 infants born before 35 weeks gestational age who received both magnetic resonance imaging of the brain between 37 and 44 weeks corrected gestational age and developmental assessment around 18 months corrected age.

RESULTS

No relationships were found between ADC values and MRS results or outcome. MRS ratios involving N-acetyl aspartate (NAA) from the posterior white matter were associated with "severe" and "moderate to severe" difficulties, and fine motor scores were significantly lower in participants with a visible lactate doublet in the posterior white matter. The presence of a patent ductus arteriosus (PDA) was the only clinical factor related to NAA ratios.

CONCLUSION

Altered NAA levels in the posterior white matter may reflect subtle white matter injury associated with neuro-developmental difficulties, which may be related to a PDA. Further work is needed to assess the longer-term neuro-developmental implications of these findings, and to study the effect of PDAs on developmental outcome in later childhood/adolescence.

Highlighting the threat from current and near-future ozone pollution to clover in pasture

Globally, the legume-rhizobia symbiosis, contained within specialised organs called root nodules, is thought to add at least 30 Tg N annually to agricultural land. The growth and functioning of a modern white clover (Trifolium repens cv. Crusader) and red clover (T. pratense cv. Merviot) cultivar were investigated in current and future ozone scenarios in solardomes. Both cultivars developed leaf injury and had significant reductions in root biomass and root nodule number in response to ozone, with Crusader also displaying a reduced size and mass of nodules. In-situ measurements of N-fixation in Crusader by acetylene reduction assay revealed reduced N-fixation rates in a future scenario with an increased background and moderate peaks of ozone. The implications for the sustainability of temperate pasture are discussed.

Systematic review of lifestyle interventions to limit postpartum weight retention: implications for future opportunities to prevent maternal overweight and obesity following childbirth

Postpartum weight retention can predict future weight gain and long-term obesity. Moreover, failure to lose weight gained during pregnancy can lead to increased body mass index for subsequent pregnancies, increasing the risk of adverse maternal and foetal pregnancy outcomes. This systematic review evaluates the effectiveness of lifestyle interventions aimed at reducing postpartum weight retention. Seven electronic databases were searched for intervention studies and trials enrolling women with singleton pregnancies and published in English from January 1990 to October 2012. Studies were included when postpartum weight was a main outcome and when diet and/or exercise and/or weight monitoring were intervention components. No limitations were placed on age, body mass index or parity. Eleven studies were identified as eligible for inclusion in this review, of which 10 were randomized controlled trials. Seven studies were successful in decreasing postpartum weight retention, six of which included both dietary and physical activity components, incorporated via a range of methods and delivered by a variety of health practitioners. Few studies utilized modern technologies as alternatives to traditional face-to-face support and cost-effectiveness was not assessed in any of the studies. These results suggest that postpartum weight loss is achievable, which may form an important component of obesity prevention in mothers; however, the optimal setting, delivery, intervention length and recruitment approach remains unclear.

SPRING: an RCT study of probiotics in the prevention of gestational diabetes mellitus in overweight and obese women

Background

Obesity is increasing in the child-bearing population as are the rates of gestational diabetes. Gestational diabetes is associated with higher rates of Cesarean Section for the mother and increased risks of macrosomia, higher body fat mass, respiratory distress and hypoglycemia for the infant. Prevention of gestational diabetes through life style intervention has proven to be difficult. A Finnish study showed that ingestion of specific probiotics altered the composition of the gut microbiome and thereby metabolism from early gestation and decreased rates of gestational diabetes in normal weight women. In SPRING (the Study of Probiotics IN the prevention of Gestational diabetes), the effectiveness of probiotics ingestion for the prevention of gestational diabetes will be assessed in overweight and obese women.

Methods/design

SPRING is a multi-center, prospective, double-blind randomized controlled trial run at two tertiary maternity hospitals in Brisbane, Australia. Five hundred and forty (540) women with a BMI > 25.0 kg/m² will be recruited over 2 years and receive either probiotics or placebo capsules from 16 weeks gestation until delivery. The probiotics capsules contain > 1x10⁹ cfu each of Lactobacillus rhamnosus GG and Bifidobacterium lactis BB-12 per capsule. The primary outcome is diagnosis of gestational diabetes at 28 weeks gestation. Secondary outcomes include rates of other pregnancy complications, gestational weight gain, mode of delivery, change in gut microbiome, preterm birth, macrosomia, and infant body composition. The trial has 80% power at a 5% 2-sided significance level to detect a >50% change in the rates of gestational diabetes in this high-risk group of pregnant women.

Discussion

SPRING will show if probiotics can be used as an easily implementable method of preventing gestational diabetes in the high-risk group of overweight and obese pregnant women.

Focus groups in health research: exploring the meanings of health and illness

Focus group method is becoming increasingly popular among qualitative researchers. After introducing focus group method and briefly overviewing its use in health research, this article shows that the distinctive (and under-used) feature of focus group method is its generation of interactive data. Illustrating my argument with examples from health- related focus group research (including my own data on breast cancer), I argue that this feature makes focus groups an ideal method for gaining access to research participants' own meanings. Interactive data result in enhanced disclosure, improved access to participants' own language and concepts, better understanding of participants' own agendas, the production of more elaborated accounts, and the opportunity to observe the co-construction of meaning in action. Focus groups are, then, an ideal method for exploring people's own meanings and understandings of health and illness.

Excess gestational weight gain: an exploration of midwives' views and practice

BACKGROUND

Excess gestational weight gain (GWG) can affect the immediate and long term health outcomes of mother and infant. Understanding health providers' views, attitudes and practices around GWG is crucial to assist in the development of practical, time efficient and cost effective ways of supporting health providers to promote healthy GWGs. This study aimed to explore midwives' views, attitudes and approaches to the assessment, management and promotion of healthy GWG and to investigate their views on optimal interventions.

METHODS

Midwives working in antenatal care were recruited from one rural and one urban Australian maternity hospital employing purposive sampling strategies to assess a range of practice areas. Face-to-face interviews were conducted with 15 experienced midwives using an interview guide and all interviews were digitally recorded, transcribed verbatim and analysed thematically.

RESULTS

Midwives interviewed exhibited a range of views, attitudes and practices related to GWG. Three dominant themes emerged. Overall GWG was given low priority for midwives working in the antenatal care service in both hospitals. In addition, the midwives were deeply concerned for the physical and psychological health of pregnant women and worried about perceived negative impacts of discussion about weight and related interventions with women. Finally, the midwives saw themselves as central in providing lifestyle behaviour education to pregnant women and identified opportunities for support to promote healthy GWG.

CONCLUSIONS

The findings indicate that planning and implementation of healthy GWG interventions are likely to be challenging because the factors impacting on midwives' engagement in the GWG arena are varied and complex. This study provides insights for guideline and intervention development for the promotion of healthy GWG.

Lung cancer mortality in a cohort of UK cotton workers: an extended follow-up

Background:

A recent systematic review and meta-analysis suggested that occupational exposure to endotoxins protects against lung cancer. To explore this hypothesis further, the follow-up of mortality of a cohort of 3551 workers, who were employed in the British cotton industry during 1966–1971, was extended by 23 years.

Methods:

Subjects had originally been recruited to a survey of respiratory disease, which collected information about occupation and smoking habits. Cumulative exposures to endotoxins were estimated from data on endotoxin levels by work areas in cotton mills. Risks of lung cancer were estimated using survival modelling.

Results:

During follow-up, 2018 deaths were recorded before the age of 90 years, including 128 deaths from lung cancer. After adjustment for smoking, hazard ratios (95% confidence intervals) for cumulative endotoxin exposures of ⩽30 000, >30 000 and ⩽200 000, >200 000 and ⩽400 000, >400 000 and ⩽600 000 and >600 000 endotoxin units (EU) m⁻³ years were 1, 0.8 (0.5–1.6), 0.7 (0.4–1.3), 0.6 (0.3–1.0) and 0.5 (0.3–0.9), respectively (P for trend=0.005).

Conclusion:

Our findings strengthen the evidence that occupational exposure to endotoxins protects against lung cancer, and suggest that the effect depends on cumulative dose and persists after exposure ceases.

The ToT study: helping with Touch or Talk (ToT): a pilot randomised controlled trial to examine the clinical effectiveness of aromatherapy massage versus cognitive behaviour therapy for emotional distress in patients in cancer/palliative care

Distress associated with cancer often presents with symptoms of depression and/or anxiety. Cognitive Behaviour Therapy (CBT) is one of the most effective psychological treatments. Complementary therapies, especially aromatherapy massage (AM), are also popular and alleviate anxiety. No studies have directly compared these two treatments.

AIMS

The aim of this study is to (1) test the feasibility of recruitment into a randomised controlled trial of AM versus CBT in patients with cancer; (2) test and modify the intervention; (3) determine whether changes in outcomes were consistent with published data.

METHODS

Patients at all stages of cancer, recruited from oncology outpatient clinics and screening eight or more for anxiety and/or depression on the HADS, were randomised to Treatment as Usual (TAU) plus up to eight sessions weekly of either AM or CBT, offered within 3 months. The POMS was collected at baseline and 3 and 6 months post baseline.

RESULTS

Of those suitable, over 60% (39/63) participated (AM, n = 20; CBT, n = 19) and over 90% (36/39) were followed up. Both packages were well received. The preference was for AM, with more sessions were taken up; (Mean number sessions AM = 7.2 (SD 2.0) and CBT = 5.4 (SD 3.1); P<0.05). Significant improvements in POMS (Total Mood, depression and anxiety scores) occurred with both interventions. Between-group comparison showed a non-significant trend towards greater improvement in depression with CBT.

CONCLUSIONS

Recruitment was feasible; the interventions acceptable and engagement with treatment was high. Improvements with both interventions were observed. The beneficial effects on depression with CBT appeared to be sustained.

Antibiotic use in elderly hospital inpatients before and after the introduction of treatment guidelines

Objective

(1) To establish the pattern of antibiotic use in elderly hospital inpatients, using data to draw up antibiotic treatment guidelines; (2) To assess the short-term and longer-term impact of the guidelines on antibiotic use and their acceptability to medical staff.

Method

Antibiotic use was assessed in relation to suitability for site and severity of infection, appropriateness of drug choice, outcome of therapy and cost, before, immediately after and 10 months after guideline introduction. Acceptability to medical staff was gauged through a questionnaire.

Setting

Geriatric hospital inpatients in long-stay, assessment and GP-supervised wards in the Grampian region of Scotland (phase 1: 324 patients; phase 2: 302 patients; phase 3: 263 patients).

Key findings

The antibiotic prescribed was appropriate for site and severity of infection in 92 per cent of patients in phase 1, but was a policy drug in only 56 per cent. After guideline introduction, adherence to policy did not improve, but use of non-policy drugs without identified reason fell from 24 per cent in phase 1 to 13 per cent in phase 3. Adjustment of antibiotic dose for renal function increased from 73 per cent in phase 1 to 86 per cent in phase 3. Duration of treatment for a single infection was significantly reduced in phase 3, but outcome and cost were unchanged after guideline introduction. Medical staff were supportive of the guidelines and felt they had changed their prescribing practices.

Conclusion

Antibiotic treatment guidelines did not have a major impact on antibiotic use, although some positive trends were observed. New ways of promoting adherence to guidelines need to be explored.

A meta-analysis into the effect of lateral-wedged insoles with subtalar strapping versus traditional insoles in adults with medial knee osteoarthritis

To  systematically  identify,  collate,  and  analyze  the  current available evidence  for  the  effectiveness  of  lateral-wedged  insoles,  with subtalar strapping,  on  reducing  pain,  improving  function  and  improving  the femoral-tibial  angle  (FTA),  in  adults  with  medial  knee osteoarthritis compared to traditional insoles without subtalar strapping.Six computerised databases, namely Cochrane Library, CiNAHL, PEDro, BIOMED central,  PubMed  and  ScienceDirect  were  searched. The  included articles were  then  all  rated  using  the  PEDro  scale  to  determine  their meth-odological quality.  Homogeneous data were pooled in a meta-analysis using Review Manager (REVMAN) software.  Where statistical pooling of the results was not possible, findings were summarised in narrative form. Three randomised controlled trials were selected for this review. The average PEDro score was 5.7. A meta-analysis demonstrated that lateral-wedged insoles with subtalar strapping significantly reduced pain in the short-term (p=0.004). The review found that lateral-wedge insoles with subtalar strapping significantly decreased pain in the short-term and seemed to have a positive effect on the FTA in the long-term, when compared to traditional insoles without  subtalar strapping. The lateral-wedge insole with subtalar strapping may provide a financially feasible adjunctive self-management treatment for knee OA and should be considered before invasive procedures such as surgery.

Could the NEC be widely used in New Zealand?

One of the major changes in the UK construction industry in recent years has been wide adoption of the NEC suite of contracts. The aim of this research was to investigate whether the drivers for change to the NEC are currently present in New Zealand, along with investigation of the value the NEC is likely to add and the factors that will influence the NEC’s wider adoption. Senior construction industry players (including clients, consultants and contractors) were surveyed to investigate these research aims. A combination of in-depth semi-structured interviews were undertaken initially, followed by an internet-based survey to seek wider consensus on the thoughts, ideas and opinions of the interviewed research sample. The research found that the drivers for change to facilitate the adoption of the NEC are currently not significant in New Zealand construction. The study demonstrated that industry players generally believe the features and principles of the NEC would be beneficial, with project experiences for the most part confirming support for the contract. The conclusion reached by this research is that for wider adoption of the NEC to ‘add value’ within New Zealand construction, improvements in project management and procurement practices will be required.