Gestational diabetes mellitus in early pregnancy amongst Asian Indian women: Evidence for poor pregnancy outcomes despite treatment

AIM

To compare the pregnancy outcomes in women with gestational diabetes (GDM) based on the timing of diagnosis.

METHODS

This retrospective cohort study was conducted between January 2011 and September 2017 amongst 2638 Asian Indian pregnant women. The inclusion criteria included; singleton pregnancies having HbA1c <48 mmols/mol (6.5%) in the first trimester, GDM screening by 75 g OGTT using IADPSG criteria and delivery at our centre. The cohort was divided into 3 groups: Early GDM (E-GDM)-diagnosis <24 gestational weeks (Gw), Standard GDM (S-GDM)-diagnosis ≥24Gw, Non-GDM- No GDM ≥24 Gw. Multivariable logistic regression models compared the pregnancy outcomes between Non-GDM, S-GDM and E-GDM groups. A sub-group multivariable analysis was done amongst GDM women using gestational age at diagnosis both as a categorical and continuous variable.

RESULTS

Compared to Non-GDM women, the odds were higher for premature birth, large for gestational age (LGA) babies, macrosomia, Neonatal ICU(NICU) admission and lower for normal vaginal delivery in the E-GDM group, but for the S-GDM group, the risk was higher for premature birth, LGA babies, NICU admission and induction of labour. Compared to GDM women in the 24-28 Gw category significantly higher odds for premature birth and LGA babies were observed in the <14 Gw category. A continuous increase of 19% odds for premature birth with every 4 weeks decrease in gestational age at GDM diagnosis was observed.

CONCLUSIONS

Asian Indian women having a GDM diagnosis before 24Gw are at higher risk for adverse pregnancy events than those having diagnosis ≥24Gw or not having GDM.

Is HbA1c in the first trimester associated with adverse outcomes among pregnant Asian Indian women without gestational diabetes?

AIMS

The aim of this study is to determine the association of elevated HbA1c in the first trimester (HbA1c-FT) with adverse events among pregnant Asian Indian women without gestational diabetes (GDM).

METHODS

This retrospective cohort study included 1618 pregnant women who delivered at a single urban tertiary care center and had HbA1c-FT estimation between January 2011 and September 2017. Those with GDM according to a 75-g OGTT after 24 gestational weeks were excluded. Multivariable logistic regression models assessed the association between elevated HbA1c-FT and adverse events.

RESULTS

At a cutoff of ≥37 mmol/mol (5.5%), HbA1c-FT was associated with preterm birth at <37 gestational weeks (adjusted odds ratio (OR) 2.10, 95% CI 1.11-3.98). There was a continuum of risk for primary caesarean delivery with higher HbA1c-FT levels (adjusted OR per 5-mmol/mol (0.5%) increase in HbA1c-FT for primary caesarean delivery: 1.27, 95% CI 1.06-1.52). In the crude analysis, gestational hypertension was associated with HbA1c-FT, but not after adjustment for confounding factors. HbA1c-FT was not associated with other adverse events (macrosomia, large for gestational age babies, or other neonatal complications).

CONCLUSIONS

Even without GDM, the results suggest an association of HbA1c-FT with preterm birth and primary caesarian delivery among Asian Indian women.

Nasal Continuous Positive Airway Pressure in Bronchiolitis: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of nasal continuous positive airway pressure (nCPAP) in decreasing respiratory distress in bronchiolitis.

DESIGN

Randomized controlled trial.

SETTING

Tertiary-care hospital in New Delhi, India. Participants: 72 infants (age <1y) hospitalized with a clinical diagnosis of bronchiolitis were randomized to receive standard care, or nCPAP in addition to standard care, in the first hour after admission. 23 parents refused to give consent for participation. 2 infants did not tolerate nCPAP.

PARTICIPANTS

72 infants (age <1y) hospitalized with a clinical diagnosis of bronchiolitis were randomized to receive standard care, or nCPAP in addition to standard care, in the first hour after admission. 23 parents refused to give consent for participation. 2 infants did not tolerate nCPAP.

INTERVENTION

The outcome was assessed after 60 minutes. If nCPAP was not tolerated or the distress increased, the infant was switched to standard care. Analysis was done on intention-to-treat basis.

MAIN OUTCOME MEASURES

Change in respiratory rate, Silverman-Anderson score and a Modified Pediatric Society of New Zealand Severity Score.

RESULTS

14 out of 32 in nCPAP group and 5 out of 35 in standard care group had change in respiratory rate ≥10 (P=0.008). The mean (SD) change in respiratory rate [8.0 (5.8) vs 5.1 (4.0), P=0.02] in Silverman-Anderson score [0.78 (0.87) vs 0.39 (0.73), P=0.029] and in Modified Pediatric Society of New Zealand Severity Score [2.5 (3.01) vs. 1.08 (1.3), P=0.012] were significantly different in the nCPAP and standard care groups, respectively.

CONCLUSIONS

nCPAP helped reduce respiratory distress significantly compared to standard care.

Nasal Continuous Positive Airway Pressure in Bronchiolitis: A Randomized Controlled Trial

Objective

To evaluate the efficacy of nasal continuous positive airway pressure (nCPAP) in decreasing respiratory distress in bronchiolitis.

Design

Randomized controlled trial.

Setting

Tertiary-care hospital in New Delhi, India.

Participants

72 infants (age < 1y) hospitalized with a clinical diagnosis of bronchiolitis were randomized to receive standard care, or nCPAP in addition to standard care, in the first hour after admission. 23 parents refused to give consent for participation. 2 infants did not tolerate nCPAP.

Intervention

The outcome was assessed after 60 minutes. If nCPAP was not tolerated or the distress increased, the infant was switched to standard care. Analysis was done on intention-to-treat basis.

Main outcome measures

Change in respiratory rate, Silverman-Anderson score and a Modified Pediatric Society of New Zealand Severity Score.

Results

14 out of 32 in nCPAP group and 5 out of 35 in standard care group had change in respiratory rate ≥10 (P=0.008). The mean (SD) change in respiratory rate[8.0 (5.8) vs 5.1 (4.0), P=0.02] in Silverman-Anderson score [0.78 (0.87) vs 0.39 (0.73), P=0.029] and in Modified Pediatric Society of New Zealand Severity Score [2.5 (3.01) vs. 1.08 (1.3), P=0.012] were significantly different in the nCPAP and standard care groups, respectively.

Conclusion

nCPAP helped reduce respiratory distress significantly compared to standard care.

Food Choices and Consequences for the Nutritional Status: Insights into Nutrition Transition in an Hospital Community

Introduction

Although economic development is generally accompanied by improvements in the overall nutritional status of the country’s population the ‘nutritional transition’ often involves a shift to high energy diets and less exercise with negative consequences. This pilot study was done to examine if education of parents operates at the household level to influence dietary choices and the nutritional status of children in a small community of hospital workers.

Material and Methods

3 groups of persons with varying skill and education levels participated. Weighed food logs were used in all households to calculate ‘adult equivalent’ per-capita-consumption. Nutrients were calculated using nutrients calculator software. BMI was used to classify children as underweight, normal weight and overweight.

Results

128 individuals participated from 30 families included 47 children. 10 children (21%) were underweight, 29 (62%) were normal and 8 (17%) were overweight. Energy consumption was highest in families with overweight children 2692 +/-502 compared to 2259 +/-359 in families with normal weight and 2031+/-354 in the family of underweight children. These differences were statistically significant. 42% underweight children belonged to Class 1 at the lowest skill level and there were no overweight children in this group. Most of the overweight children belonged to Class 2. In Class 3 there were no underweight children and the majority was normal weight children.

Conclusion

Underweight children came from the poorer households. Per capita intake of the family as a whole correlated well with BMI in the children. There was increased obesity in middle income families belonging to Class 2—probably in families who move up the scale from deprivation. Nutritional status in children correlated mostly with maternal education status.

P3-14-21: Neoadjuvant Therapy Response, Subtype and BRCA Status in an Underserved Population

Background

Preoperative (neoadjuvant) chemotherapy is typically used for larger operable breast cancer cases, and the degree of pathological response correlates with long term outcome. Therapeutic response also depends on biological and molecular subtype and is increasingly studied in the research setting to identify prognostic biomarkers and potential therapeutic targets. Little is known about the interactions of neoadjuvant response with biomarker subtypes and genetic predisposition in underserved and minority populations.

Methods: IRB approval was obtained to capture demographic, clinicopathological and genetic testing data on patients diagnosed with invasive breast cancer and treated with preoperative chemotherapy and definitive surgery between 2005 and 2010 at Los Angeles County Medical Center, which serves a primarily Hispanic and indigent population. Treatment followed NCCN guidelines with the exception that not all patients with HER2+ disease received trastuzumab. Genetic counseling and testing has been available at this center since 2007. Pathological complete response (pCR) was defined as no residual invasive disease in breast or nodes. Chi-square or Fisher's Exact test was used to examine associations between pCR and clinical factors, and logistic regression analyses were applied to assess each variable's contribution to pCR.

Results: Among 104 patients, of whom 79% were Hispanic, the overall pCR rate was 27%. Significantly higher pCR rates were seen in age ≥50, clinical N0, HER2+, triple negative, and lumpectomy cases. No differences in pCR rate was seen in Hispanics vs. others, Grade III vs. I and II or in the 9 BRCA mutations carriers among 45 tested compared to no mutation or those not tested. Of the 43 patients with HER2+ disease, the pCR rate was higher in the 32 patients who received trastuzumab (pCR 50.0 vs. 27.3%). Subset pCR rates and odds ratios (OR) of achieving pCR are shown below:

Pictorial essay: Mammography of the male breast

Mammography is an imaging modality that is widely perceived to be of use only in women for the detection and diagnosis of breast pathologies. Here, we present a pictorial essay on the mammographic spectrum of male breast pathologies.

Human cultured dendritic cells show differential sensitivity to chemotherapy agents as assessed by the MTS assay

Assessment of the chemosensitivity of dendritic cells (DC) may allow more rational development of combined chemotherapy and immunotherapy protocols. Human monocyte-derived DC generated reproducible results in the MTS (Owen's reagent) assay, which was then used to study DC survival after treatment with four different chemotherapy agents. DC preparations from three different donors were used per drug. DC were sensitive to doxorubicin (concentration range 0.1-50 microM) with variation in sensitivity between donors (IC50 244-1100 nM). The most extreme variation was seen for vinblastine (concentration range 250-0.025 microM with IC50 0.15-17.25 microM). In contrast, there was relative resistance to etoposide (concentration range 0.2-200 microM) and 5-fluorouracil (concentration range 0.7-7700 microM) with no toxicity seen until 50 microM and 770 microM respectively. The function of DC in allogeneic mixed leucocyte reactions closely paralleled results from the MTS assays. The differential sensitivity to chemotherapy agents did not appear to be due to expression of P-glycoprotein. These results suggest that etoposide or 5-fluorouracil is less likely to reduce the immunotherapeutic potential of DC and may be valuable in the design of prodrug activation therapy.

Usefulness of immunoperoxidase test for serodiagnosis of genital chlamydial infections

An immunoperoxidase test detecting Chlamydia trachomatis specific serum IgG and IgA antibodies, was carried out to determine its efficacy in establishing chlamydial etiology in 104 clinically diagnosed patients attending a major STD Clinic in Delhi. The patients consisted of 58 with nonspecific urethritis/cervicitis (NSU/NSC), 11 with pelvic inflammatory disease (PID), 23 with primary infertility in either male or female and 12 with lymphogranuloma venereum (LGV). IgG antibodies were tested at a dilution of 1:64 and 1:128 and IgA antibodies at 1:16. Although 27.7 per cent (5 of 18) of the controls had IgG antibodies (> or = 1:128), none had IgA, showing the IgA marker as 100 per cent specific. In 80.8 per cent of all the patients, active infection was detected, 81.0 per cent in NSU/NSC, 81.8 per cent in PID, 76.9 per cent in female infertility, 80 per cent in male infertility and 83.3 per cent in LGV patients. The immunoperoxidase test was found to be an extremely simple and rapid test especially suited for laboratories where facilities are limited.