Gestational diabetes in twin pregnancies-a pathology requiring treatment or a benign physiological adaptation?

There is level-1 evidence that screening for and treating gestational diabetes in singleton pregnancies reduce maternal and neonatal morbidity. However, similar data for gestational diabetes in twin pregnancies are currently lacking. Consequently, the current approach for the diagnosis and management of gestational diabetes in twin pregnancies is based on the same diagnostic criteria and glycemic targets used in singleton pregnancies. However, twin pregnancies have unique physiological characteristics, and many of the typical gestational diabetes-related complications are less relevant for twin pregnancies. These differences raise the question of whether the greater increase in insulin resistance observed in twin pregnancies (which is often diagnosed as diet-treated gestational diabetes) should be considered physiological and potentially beneficial in which case alternative criteria should be used for the diagnosis of gestational diabetes in twin pregnancies. In this review, we summarize the most up-to-date evidence on the epidemiology, pathophysiology, and clinical consequences of gestational diabetes in twin pregnancies and review the available data on twin-specific screening and diagnostic criteria for gestational diabetes. Although twin pregnancies are associated with a higher incidence of diet-treated gestational diabetes, diet-treated gestational diabetes in twin pregnancies is less likely to be associated with adverse outcomes and accelerated fetal growth than in singleton pregnancies and may reduce the risk for intrauterine growth restriction. In addition, there is currently no evidence that treatment of diet-treated gestational diabetes in twin pregnancies improves outcomes, whereas preliminary data suggest that strict glycemic control in such cases might increase the risk for intrauterine growth restriction. Overall, these findings provide support to the hypothesis that the greater transient increase in insulin resistance observed in twin pregnancies is merely a physiological exaggeration of the normal increase in insulin resistance observed in singleton pregnancies (that is meant to support 2 fetuses) rather than a pathology that requires treatment. These data illustrate the need to develop twin-specific screening and diagnostic criteria for gestational diabetes to avoid overdiagnosis of gestational diabetes and to reduce the risks associated with overtreatment of diet-treated gestational diabetes in twin pregnancies. Although data on twin-specific screening and diagnostic criteria are presently scarce, preliminary data suggest that the optimal screening and diagnostic criteria in twin pregnancies are higher than those currently used in singleton pregnancies.

Glycemic control and neonatal outcomes in twin pregnancies with gestational diabetes mellitus

BACKGROUND

Preliminary data suggest that strict glycemic control in twin pregnancies with gestational diabetes mellitus may not improve outcomes but might increase the risk of fetal growth restriction.

OBJECTIVE

This study aimed to investigate the association of maternal glycemic control with the risk of gestational diabetes mellitus-related complications and small for gestational age in twin pregnancies complicated by gestational diabetes mellitus.

STUDY DESIGN

This was a retrospective cohort study of all patients with a twin pregnancy complicated by gestational diabetes mellitus in a single tertiary center between 2011 and 2020, and a matched control group of patients with a twin pregnancy without gestational diabetes mellitus in a 1:3 ratio. The exposure was the level of glycemic control, described as the proportion of fasting, postprandial, and overall glucose values within target. Good glycemic control was defined as a proportion of values within target above the 50th percentile. The first coprimary outcome was a composite variable of neonatal morbidity, defined as at least 1 of the following: birthweight >90th centile for gestational age, hypoglycemia requiring treatment, jaundice requiring phototherapy, birth trauma, or admission to the neonatal intensive care unit at term. A second coprimary outcome was small for gestational age, defined as birthweight <10th centile or <3rd centile for gestational age. Associations between the level of glycemic control and the study outcomes were estimated using logistic regression analysis and were expressed as adjusted odds ratio with 95% confidence interval.

RESULTS

A total of 105 patients with gestational diabetes mellitus in a twin pregnancy met the study criteria. The overall rate of the primary outcome was 32.4% (34/105), and the overall proportion of pregnancies with a small for gestational age newborn at birth was 43.8% (46/105). Good glycemic control was not associated with a reduction in the risk of composite neonatal morbidity when compared with suboptimal glycemic control (32.1% vs 32.7%; adjusted odds ratio, 2.06 [95% confidence interval, 0.77-5.49]). However, good glycemic control was associated with higher odds of small for gestational age compared with nongestational diabetes mellitus pregnancies, especially in the subgroup of diet-treated gestational diabetes mellitus (65.5% vs 34.0%, respectively; adjusted odds ratio, 4.17 [95% confidence interval, 1.74-10.01] for small for gestational age <10th centile; and 24.1% vs 7.0%, respectively; adjusted odds ratio, 3.97 [95% confidence interval, 1.42-11.10] for small for gestational age <3rd centile). In contrast, the rate of small for gestational age in gestational diabetes mellitus pregnancies with suboptimal control was not considerably different when compared with non-gestational diabetes mellitus pregnancies. In addition, in cases of diet-treated gestational diabetes mellitus, good glycemic control was associated with a left-shift of the distribution of birthweight centiles, whereas the distribution of birthweight centiles among gestational diabetes mellitus pregnancies with suboptimal control was similar to that of nongestational diabetes mellitus pregnancies.

CONCLUSION

In patients with gestational diabetes mellitus in a twin pregnancy, good glycemic control is not associated with a reduction in the risk of gestational diabetes mellitus-related complications but may increase the risk of a small for gestational age newborn in the subgroup of patients with mild (diet-treated) gestational diabetes mellitus. These findings further question whether the gestational diabetes mellitus glycemic targets used in singleton pregnancies also apply to twin pregnancies and support the concern that applying the same diagnostic criteria and glycemic targets in twin pregnancies may result in overdiagnosis and overtreatment of gestational diabetes mellitus and potential neonatal harm.

Patient-reported outcome measures for assessing health-related quality of life in people with type 2 diabetes: A systematic review

Patient-Reported Outcome Measures (PROMs) are important tools to assess outcomes relevant to patients, with Health-Related Quality Of Life (HRQOL) as an important construct to be measured. Many different HRQOL PROMs are used in the type 2 diabetes field, however a complete overview of these PROMs is currently lacking. We therefore aimed to systematically describe and classify the content of all PROMs that have specifically been developed or validated to measure (aspects of) HRQOL in people with type 2 diabetes. A literature search was performed in PubMed and EMBASE until 31 December 2021. Studies on the development or validation of a PROM measuring HRQOL, or aspects of HRQOL, in people with type 2 diabetes were included. Title and abstract and full-text screening were conducted by two independent researchers and data extraction was performed independently by one of the researchers. Data were extracted on language in which the PROM was developed, target population, construct(s) being measured, names of (sub)scales and number of items per (sub)scale. In addition, all PROMs and subscales were classified according to specific aspects of HRQOL based on the Wilson & Cleary model (symptom status, functional status, general health perceptions) to aid researchers in PROM selection. In total 220 studies were identified that developed or validated PROMs that measure (aspects of) HRQOL in people with type 2 diabetes. Of the 116 unique HRQOL PROMs, 91 (of the subscales) measured symptom status, 60 measured functional status and 26 measured general health perceptions. In addition, 16 of the PROMs (subscales) measured global quality of life. 61 of the 116 PROMs (subscales) also include characteristics of the individual (e.g. aspects of personality, coping) or environment (e.g. social or financial support) and patient-reported experience measures (PREMs, e.g. measure of a patient's perception of their personal experience of the healthcare they have received, e.g. treatment satisfaction), which are not part of the HRQOL construct. Only 9 of the 116 PROMs measure all aspects of HRQOL based on the Wilson & Cleary model. Finally, 8 of the 116 PROMs stating to measure HRQOL, measured no HRQOL construct. In conclusion, a large number of PROMs are available for people with type 2 diabetes, which intend to measure (aspects of) HRQOL. These PROMs measure a large variety of (sub)constructs, which are not all HRQOL constructs, with a small amount of PROMs not measuring HRQOL at all. There is a need for consensus on which aspects of HRQOL should be measured in people with type 2 diabetes and which PROMs to use in research and daily practice. PROSPERO: CRD42017071012. COMET database: http://www.comet-initiative.org/studies/details/956 .

Screening Accuracy of the 50 g-Glucose Challenge Test in Twin Compared With Singleton Pregnancies

CONTEXT

The optimal 50 g-glucose challenge test (GCT) cutoff for the diagnosis of gestational diabetes mellitus (GDM) in twin pregnancies is unknown.

OBJECTIVE

This work aimed to explore the screening accuracy of the 50 g-GCT and its correlation with the risk of large for gestational age (LGA) newborn in twin compared to singleton pregnancies. A population-based retrospective cohort study (2007-2017) was conducted in Ontario, Canada. Participants included patients with a singleton (n = 546 892 [98.4%]) or twin (n = 8832 [1.6%]) birth who underwent screening for GDM using the 50 g-GCT.

METHODS

We compared the screening accuracy, risk of GDM, and risk of LGA between twin and singleton pregnancies using various 50 g-GCT cutoffs.

RESULTS

For any given 50 g-GCT result, the probability of GDM was higher (P = .0.007), whereas the probability of LGA was considerably lower in the twin compared with the singleton group, even when a twin-specific growth chart was used to diagnose LGA in the twin group (P < .001). The estimated false-positive rate (FPR) for GDM was higher in twin compared with singleton pregnancies irrespective of the 50 g-GCT cutoff used. The cutoff of 8.2 mmol/L (148 mg/dL) in twin pregnancies was associated with an estimated FPR (10.7%-11.1%) that was similar to the FPR associated with the cutoff of 7.8 mmol/L (140 mg/dL) in singleton pregnancies (10.8%).

CONCLUSION

The screening performance of the 50 g-GCT for GDM and its correlation with LGA differ between twin and singleton pregnancies.

The prognostic value of the oral glucose tolerance test for future type-2 diabetes in nulliparous pregnant women testing negative for gestational diabetes

AIM

To determine the prognostic value of the antepartum 75g-oral glucose tolerance test (OGTT) for future type 2 diabetes mellitus (T2DM) in nulliparous pregnant women who tested negative for GDM.

METHODS

A population-based retrospective cohort study of nulliparous pregnant women who underwent testing for GDM using a 75g-OGTT in Ontario, Canada (2007-2017). The overwhelming majority of women in Ontario undergo screening using the preferred 2-step approach where the 75g-OGTT is performed following an abnormal non-fasting 1 h 50g-glucose challenge test. The relationship between the 75g-OGTT results in women who tested negative for GDM (defined as normal glucose at fasting, 1 and 2 h post 75g-glucose load) and future T2DM (as recorded in the Ontario Diabetes Database by the end date of follow up period) was explored.

FINDINGS

Of the 162,622 women who underwent 75g-OGTT during the study period, there were 41,507 (75.0%) who met the study criteria. In women without GDM, the adjusted hazard ratios (aHR) for T2DM were-At fasting 2.82 (95%-CI 2.18-3.64), at 1 h 1.26 (1.15-1.37), at 2 h 1.14 (1.04-1.25) for a 1 mmol/L increase in glucose. A model that combined all 3 OGTT values and clinical characteristics could detect 43% (42.6%-43.4%) of those who developed T2DM at 5-years post the index pregnancy for a false-positive rate of 20%.

INTERPRETATION

The results of the antepartum OGTT can be used to refine the future risk of T2DM even in nulliparous pregnant women who tested negative for GDM.

Hospital-based ambulatory clinic adoption of video and telephone visits before and during the COVID-19 pandemic: a convergent mixed-methods study

Purpose

The purpose of this study is to understand virtual care use (e.g. telephone and video visits) during the COVID-19 pandemic across three hospital-based ambulatory clinics (i.e. mental health, renal and respiratory care) and to describe associated patient and provider experiences.

Design/methodology/approach

A mixed-methods convergent study was conducted including quantitative electronic medical records data on virtual care use, electronic surveys assessing domains of experience (e.g. satisfaction, acceptance and technology use) among patient and providers and semi-structured interviews exploring the associated barriers and facilitators of virtual care adoption.

Findings

Virtual care adoption rates and relative modality use (telephone vs video) varied across specialty clinics. Mental health clinics) showed the greatest use of virtual care and greater use of video over telephone, as compared to renal and respiratory care, where telephone was used almost exclusively. Patients and providers reported an overall good satisfaction and acceptance of virtual care (60–72%) across clinics, but commonly observed barriers (technical problems, behavioral adaptations needed and inequity) persisted. Good value propositions, tech support and the presence of early adopters who can support others in workflow re-design and highlight value propositions of virtual care were listed as adoption facilitators.

Originality/value

The study provides a unique opportunity to compare the rate of virtual care adoption before and during the COVID-19 pandemic across distinct specialties that operate within the same organizational and political setting. This study showed that the nature of the condition (e.g. mental health conditions) and the characteristics of the users (e.g. younger patients) may drive models of care with higher rate of video use. Focusing on removing common barriers, like providing tech support and ensuring equitable access to patients, continues to be important even in the context of high virtual care adoption rates during the pandemic.

Gestational diabetes and fetal growth in twin compared with singleton pregnancies

BACKGROUND

Gestational diabetes mellitus is associated with accelerated fetal growth in singleton pregnancies but may affect twin pregnancies differently because of the slower growth of twin fetuses during the third trimester of pregnancy and their greater predisposition to fetal growth restriction.

OBJECTIVE

This study aimed to evaluate the association of gestational diabetes mellitus with longitudinal fetal growth in twin pregnancies and to compare this association with that observed in singleton pregnancies.

STUDY DESIGN

This was a retrospective cohort study of all women with a singleton or twin pregnancy who were followed up at a single tertiary referral center between January 2011 and April 2020. Data on estimated fetal weight and individual fetal biometric indices were extracted from ultrasound examinations of eligible women. Generalized linear models were used to model and compare the change in fetal weight and individual biometric indices as a function of gestational age between women with and without gestational diabetes mellitus in twin pregnancies and between women with and without gestational diabetes mellitus in singleton pregnancies. The primary outcome was estimated fetal weight as a function of gestational age. The secondary outcomes were longitudinal growth of individual fetal biometric indices and the rate of small for gestational age and large for gestational age at birth.

RESULTS

A total of 26,651 women (94,437 ultrasound examinations) were included in the analysis: 1881 with a twin pregnancy and 24,770 with a singleton pregnancy. The rate of gestational diabetes mellitus in the twin and singleton groups was 9.6% (n=180) and 7.6% (n=1893), respectively. The estimated fetal weight in singleton pregnancies with gestational diabetes mellitus was significantly higher than that in pregnancies without gestational diabetes mellitus (P<.001) starting at approximately 30 weeks of gestation. The differences remained similar after adjusting for maternal age, chronic hypertension, nulliparity, and neonatal sex (P<.001). In twin pregnancies, fetal growth was similar between pregnancies with and without gestational diabetes mellitus (P=.105 and P=.483 for unadjusted and adjusted models, respectively). The findings were similar to the association of gestational diabetes mellitus with the risk of large for gestational fetuses and the growth of each biometric index. When stratified by type of gestational diabetes mellitus treatment, twin pregnancies with gestational diabetes mellitus was associated with accelerated fetal growth only in the subgroup of women with medically treated gestational diabetes mellitus (P<.001), which represented 12% (n=21) of the twin pregnancy group with gestational diabetes mellitus.

CONCLUSION

In contrast to singleton pregnancies, twin pregnancies with gestational diabetes mellitus is less likely to be associated with accelerated fetal growth. This finding has raised the question of whether the diagnostic criteria for gestational diabetes mellitus and the blood glucose targets in women diagnosed with gestational diabetes mellitus should be individualized for twin pregnancies.

Oral Glucose Tolerance Test Results in Pregnancy Can Be Used to Individualize the Risk of Future Maternal Type 2 Diabetes Mellitus in Women With Gestational Diabetes Mellitus

OBJECTIVE

We aimed to quantify the risk of future maternal type 2 diabetes mellitus (T2DM) in women with gestational diabetes mellitus (GDM) based on the type and number of abnormal 75-g oral glucose tolerance test (OGTT) values and the diagnostic criteria used for the diagnosis of GDM.

RESEARCH DESIGN AND METHODS

We conducted a population-based retrospective cohort study of all nulliparous women with a live singleton birth who underwent testing for GDM using a 75-g OGTT in Ontario, Canada (2007-2017). We estimated the incidence rate (per 1,000 person-years), overall risk (expressed as adjusted hazard ratio [aHR]), and risk at 5 years after the index pregnancy of future maternal T2DM. Estimates were stratified by the type and number of abnormal OGTT values, as well as by the diagnostic criteria for GDM (Diabetes Canada [DC] vs. International Association of the Diabetes and Pregnancy Study Groups [IADPSG] criteria).

RESULTS

A total of 55,361 women met the study criteria. The median duration of follow-up was 4.4 (interquartile range 2.8-6.3; maximum 10.3) years. Using women without GDM as reference (incidence rate 2.18 per 1,000 person-years), women with GDM were at an increased risk of future T2DM; this risk was greater when using the DC compared with the IADPSG criteria (incidence rate 18.74 [95% CI 17.58-19.90] vs. 14.07 [95% CI 13.24-14.91] per 1,000 person-years, respectively). The risk of future maternal T2DM increased with the number of abnormal OGTT values and was highest for women with three abnormal values (incidence rate 49.93 per 1,000 person-years; aHR 24.57 [95% CI 21.26-28.39]). The risk of future T2DM was also affected by the type of OGTT abnormality: women with an abnormal fasting value had the greatest risk, whereas women with an abnormal 2-h value had the lowest risk (aHR 14.09 [95% CI 12.46-15.93] vs. 9.22 [95% CI 8.19-10.37], respectively). Similar findings to those described above were observed when the risk of T2DM at a fixed time point of 5 years after the index pregnancy was considered as the outcome of interest.

CONCLUSIONS

In women with GDM, individualized information regarding the future risk of T2DM can be provided based on the type and number of abnormal OGTT values, as well as the diagnostic criteria used for the diagnosis of GDM.

The screening performance of glucose challenge test for gestational diabetes in twin pregnancies: a systematic review and meta-analysis

BACKGROUND

The screening accuracy of the 50 g-glucose challenge test (50 g-GCT) for gestational diabetes (GDM) has been described in singleton pregnancies. Given the physiologic differences and greater increase in insulin resistance in twin compared with singleton pregnancies, the performance of the 50 g-GCT in twin pregnancies may differ.

OBJECTIVES

To perform a systematic review on the screening performance of the 50 g-GCT for gestational diabetes in twin pregnancies.

DATA SOURCES

Ovid Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL).

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included randomized controlled trials or cohort studies that evaluated the screening accuracy of the 50 g-GCT for GDM in twin pregnancies using the two-step approach. The primary outcome was the positive predictive value of the 50 g-GCT for GDM using the 140 mg/dL (7.8 mmol/L) threshold.

STUDY APPRAISAL AND SYNTHESIS METHODS

Methodological quality of included studies was assessed using the QUADAS-2 tool. The positive predictive value (PPV) was pooled for studies that used similar test characteristics.

RESULTS

From 2044 citations, 7 retrospective cohort studies with a total of 55,597 participants were included (6.5% twins and 93.5% singletons). The majority of studies evaluated a 50-g GCT cutoff point of 140 mg/dL. The pooled PPV for a threshold of 140 mg/dL (7.8 mmol/L) for twins was 22.58% (95% CI: 0.1912-0.2647, I²=34.1%). The 50-g GCT screen positive rate in twin pregnancies was higher than that in singleton pregnancies. None of the studies performed routine OGTT.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The PPV of 50 g-GCT for GDM in twin pregnancies when using a threshold of 140 mg/dL (7.8 mmol/L) is approximately 23%. There is currently no data on the sensitivity and specificity of the 50 g-GCT in twins.

DEVELOPING twin-specific 75-g oral glucose tolerance test diagnostic thresholds for gestational diabetes based on the risk of future maternal diabetes: a population-based cohort study

OBJECTIVE

To develop twin-specific outcome-based oral glucose tolerance test (OGTT) diagnostic thresholds for GDM based on the risk of future maternal type-2 diabetes.

DESIGN

A population-based retrospective cohort study (2007-2017).

SETTING

Ontario, Canada.

METHODS

Nulliparous women with a live singleton (n = 55 361) or twin (n = 1308) birth who underwent testing for gestational diabetes mellitus (GDM) using a 75-g OGTT in Ontario, Canada (2007-2017). We identified the 75-g OGTT thresholds in twin pregnancies that were associated with similar incidence rates of future type-2 diabetes to those associated with the standard OGTT thresholds in singleton pregnancies.

RESULTS

For any given 75-g OGTT value, the incidence rate of future maternal type-2 diabetes was lower for women with a twin than women with a singleton pregnancy. Using women with a negative OGTT as reference, the risk of future maternal type-2 diabetes in twin pregnancies with a positive OGTT based on the standard OGTT thresholds (9.86 per 1000 person years, adjusted hazard ratio (aHR) 4.79, 95% CI 2.69-8.51) was lower than for singleton pregnancies with a positive OGTT (18.74 per 1000 person years, aHR 8.22, 95% CI 7.38-9.16). The twin-specific OGTT fasting, 1-hour and 2-hour thresholds identified in the current study based on correlation with future maternal type-2 diabetes were 5.8 mmol/l (104 mg/dl), 11.8 mmol/l (213 mg/dl) and 10.4 mmol/l (187 mg/dl), respectively.

CONCLUSIONS

We identified potential twin-specific OGTT thresholds for GDM that are associated with a similar risk of future type-2 diabetes to that observed in women diagnosed with GDM in singleton pregnancies based on standard OGTT thresholds.

TWEETABLE ABSTRACT

Potential twin-specific OGTT thresholds for GDM were identified.

Variability of Clinical Practice Management of Type 1 and Type 2 Diabetes During Surgery Across Canada

OBJECTIVE

As part of a larger project to develop quality standards in perioperative diabetes management, the goal of this project was to assess self-reported management of surgical patients with diabetes across healthcare institutions and specialties in Canada.

METHODS

Current practice of perioperative management of patients with diabetes was assessed using multiple-choice questions based on commonly encountered clinical scenarios involving patients with type 1 and type 2 diabetes. The survey was sent to a broad stakeholder group of individuals involved in perioperative medicine in academic and community settings across Canada.

RESULTS

Responses to clinical case scenarios demonstrated more consistent approaches for patients with type 1 diabetes undergoing cardiac surgery, possibly reflecting more robust evidence. There was more variability in the management of noninsulin antihyperglycemic agents and hyperglycemia in patients with type 2 diabetes undergoing noncardiac surgery.

CONCLUSIONS

Given the variability in clinical practice, standards and clinical tools are required for perioperative and periprocedural glycemic management in Canada to inform practice, improve the experience and outcomes for people with diabetes and provide a foundation for quality improvement initiatives and benchmarking.

Systematic Evaluation of Canadian Diabetes Smartphone Applications for People With Type 1, Type 2 and Gestational Diabetes

OBJECTIVES

Our aims in this study were to: 1) review diabetes apps available in Canada using the Mobile App Rating Scale tool and generate usability scores for each, 2) characterize availability of features across all apps, 3) evaluate the clinical safety of bolus insulin calculators and 4) evaluate the quality of exportable blood glucose reports meant for use by health-care providers.

METHODS

Two primary reviewers searched for, screened and evaluated diabetes apps from the Android Play Store and iOS App Store, resulting from the search terms "glucose" and "diabetes."

RESULTS

Overall Mobile App Rating Scale quality rating score was 3.1 out of 5. The Functionality subsection scored the highest (3.9 out of 5) and Information scored the lowest (2.0 out of 5). The majority of apps have the ability to track carbohydrate intake (54 of 75, 72%), send reminders (46 of 75, 61%) and can generate blood glucose reports (53 of 75, 71%), but few have bolus insulin calculators (6 of 75, 9%) and remote diabetes support (10 of 75, 13%).

CONCLUSION

Despite the widespread availability of many iOS and Android diabetes management apps, few are of high quality.

Culturally Tailored Resources for South Asian Immigrant Women With Gestational Diabetes: Do They Work and What's Missing? A Qualitative Study

OBJECTIVES

Gestational diabetes mellitus (GDM) increases the risk of pregnancy complications. South Asian immigrant women have among the highest rates of GDM in Canada and they also have the highest lifelong risk of developing type 2 diabetes after a GDM pregnancy. Diabetes Canada has been developing diabetes education material that accounts for the cultural preferences of South Asians. However, there is uncertainty to whether South Asian immigrants are aware of these resources or trust them, or if other factors influence their uptake of advice.

METHODS

In this study, we conducted qualitative interviews to explore, among South Asian immigrant women with GDM: 1) their awareness of diabetes education resources, 2) their attitudes toward information from different resources and varying health-care providers and 3) their barriers and facilitators for GDM management recommendations. Gender theory is embedded in this study, as culturally specific gender roles regarding motherhood have been shown to be important to South Asian immigrant women and their perceptions of health.

RESULTS

There was an emergence of 3 main themes. First, awareness of culturally tailored educational resources is low. Second, there is an overabundance of GDM management information, which leads to variability among participants of how they rank accuracy of informational sources. Finally, there is a gender role reversal present, where women are being taken care of by their families instead of being the providers of care.

CONCLUSIONS

These results indicate that better dissemination strategies for GDM educational material are needed for health-care providers and patients, and may require additional consideration of family involvement during GDM education sessions.

Pumps or Multiple Daily Injections in Pregnancy Involving Type 1 Diabetes: A Prespecified Analysis of the CONCEPTT Randomized Trial

OBJECTIVE

To compare glycemic control, quality of life, and pregnancy outcomes of women using insulin pumps and multiple daily injection therapy (MDI) during the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT).

RESEARCH DESIGN AND METHODS

This was a prespecified analysis of CONCEPTT involving 248 pregnant women from 31 centers. Randomization was stratified for pump versus MDI and HbA_1c. The primary outcome was change in HbA_1c from randomization to 34 weeks' gestation. Key secondary outcomes were continuous glucose monitoring (CGM) measures, maternal-infant health, and patient-reported outcomes.

RESULTS

At baseline, pump users were more often in stable relationships (P = 0.003), more likely to take preconception vitamins (P = 0.03), and less likely to smoke (P = 0.02). Pump and MDI users had comparable first-trimester glycemia: HbA_1c 6.84 ± 0.71 vs. 6.95 ± 0.58% (51 ± 7.8 vs. 52 ± 6.3 mmol/mol) (P = 0.31) and CGM time in target (51 ± 14 vs. 50 ± 13%) (P = 0.40). At 34 weeks, MDI users had a greater decrease in HbA_1c (-0.55 ± 0.59 vs. -0.32 ± 0.65%, P = 0.001). At 24 and 34 weeks, MDI users were more likely to achieve target HbA_1c (P = 0.009 and P = 0.001, respectively). Pump users had more hypertensive disorders (P = 0.011), mainly driven by increased gestational hypertension (14.4 vs. 5.2%; P = 0.025), and more neonatal hypoglycemia (31.8 vs. 19.1%, P = 0.05) and neonatal intensive care unit (NICU) admissions >24 h (44.5 vs. 29.6%; P = 0.02). Pump users had a larger reduction in hypoglycemia-related anxiety (P = 0.05) but greater decline in health/well-being (P = 0.02).

CONCLUSIONS

In CONCEPTT, MDI users were more likely to have better glycemic outcomes and less likely to have gestational hypertension, neonatal hypoglycemia, and NICU admissions than pump users. These data suggest that implementation of insulin pump therapy is potentially suboptimal during pregnancy.

Developing a set of indicators to monitor quality in ambulatory diabetes care using a modified Delphi panel process

Objective

There is a large evidence to practice gap in diabetes care with limited performance assessments that capture the full spectrum of care delivery. Our study aimed to develop a set of ambulatory diabetes quality indicators across six domains (effectiveness, safety, patient-centered, timely, equitable and efficient) to provide a broad view of quality.

Design

A modified Delphi panel process was conducted. Phase I involved compiling a list of indicators through literature review and generation of patient and healthcare provider-derived indicators through interviews and surveys, respectively. Phase II involved panelists rating indicators using the Agency for Healthcare Research and Quality measure attributes on 9-point Likert scale, attending a face-to-face meeting followed by re-rating, and final ranking.

Setting

This study was conducted across five adult academic medical centers affiliated with the University of Toronto.

Participants

A multi-disciplinary Delphi panel (n = 16) including patients was assembled.

Main Outcome measure

For indicator advancement for ranking, ≥75% of panelists' responses in the top tertile (between 7 and 9) with a median composite score of ≥7 was required.

Results

There were 202 indicators included in the Delphi panel process including 171 from a comprehensive literature review, 14 from patient interviews, and 17 from healthcare provider surveys. Following the first round, 40 indicators proceeded directly to ranking, while 162 indicators were re-rated and distilled down to 12 for ranking. In the final ranking round, the 52 indicators were reduced to 35 including 13 effective, 10 safe, 6 patient-centered, 1 equitable, 3 efficient and 2 timely indicators.

Conclusion

Thirty-five selected indicators developed with broad stakeholder engagement can be used to monitor quality in diabetes care.

Incidence and risk factors for gestational diabetes mellitus in twin versus singleton pregnancies

OBJECTIVE

To compare the incidence and risk factors for gestational diabetes mellitus (GDM) between women with twin and singleton pregnancies.

METHODS

Retrospective study of all women who had a twin or singleton birth in Ontario (2012-2016). Risk ratios (RR) and 95% CIs for GDM (stratified by type of treatment) were adjusted for relevant confounding variables. Multivariable Poisson regression analysis was used to identify risk factors for GDM in twin and singleton gestations.

RESULTS

Of 270,843 women who met inclusion criteria, 266,942 (98.6%) and 3901 (1.4%) had a singleton and a twin pregnancy, respectively. Women with twins had a significantly higher risk for overall GDM (aRR = 1.13, 95% CI 1.01-1.28) and diet-treated GDM (aRR = 1.20, 95% CI 1.01-1.42) while the association with insulin-treated GDM was not significant (aRR = 1.07, 95% CI 0.89-1.28). Maternal age ≥ 35 years, non-Caucasian ethnicity and BMI > 30 kg/m² were independent risk factors for GDM among women with twins and singletons, and the magnitude of the association of these factors with GDM was similar.

CONCLUSIONS

Women with twins are at increased risk of GDM, mainly due to a higher rate of diet-treated GDM. Despite higher baseline risk of GDM in women with twins, the effect of known risk factors for GDM is similar to that observed in singletons.

Persistent and Non-Persistent High-Users of Acute Care Resources: A Deeper Dive into the Patient and System Factors

A small population of patients are responsible for the majority of Ontario's acute healthcare costs ߝ high-users of acute care. At our institution, high-users were divided into those who persisted in their high use across more than six months and those who did not. Persistent users were more likely to live alone, have more than three comorbidities, take more than five medications and be admitted for chronic diseases. In a survey of their family physicians, 58% believed no interventions could have prevented readmissions; however, useful strategies such as patient education, surgical rapid access clinics and increased mental health supports were proposed.

Accuracy of immunoassay and mass spectrometry urinary free cortisol in the diagnosis of Cushing's syndrome

PURPOSE

Urinary free cortisol (UFC) determination by highly specific methods as mass spectrometry instead of commercially available antibody-based immunoassays is increasingly recommended. However, clinical comparisons of both analytical approaches in the screening of Cushing's syndrome (CS) are not available. The aim of this study was to evaluate the diagnostic value of mass spectrometry versus immunoassay measurements of 24 h-UFC in the screening of CS.

METHODS

Cross-sectional study of 33 histologically confirmed CS patients: 25 Cushing's disease, 5 adrenal CS and 3 ectopic CS; 92 non-CS patients; and 35 healthy controls. UFC by immunoassay (UFCxIA) and mass spectrometry (UFCxMS), urinary free cortisone (UFCo) and UFC:UFCo ratio were measured, together with creatinine-corrected values. Sensitivity, specificity, AUC and Landis and Koch concordance index were determined.

RESULTS

AUC for UFCxIA and UFCxMS were 0.77 (CI 0.68-0.87) and 0.77 (CI 0.67-0.87) respectively, with a kappa coefficient 0.60 and strong Landis and Koch concordance index. The best calculated cutoff values were 359 nmol/24 h for UFCxIA (78 % sensitivity, 62 % specificity) and 258.1 nmol/24 h for UCFxMS (53 % sensitivity, 86 % specificity). The upper limit of UFCxIA and UCFxMS reference ranges were 344.7 and 169.5 nmol/24 h respectively. Sensitivity and specificity for CS diagnosis at these cutpoints were 84 and 56 % for UFCxIA and 81 and 54 % for UFCxMS.

CONCLUSIONS

According to our data, both methods present a very similar diagnostic value. However, results suggest that lower cutoff points for mass spectrometry may be necessary in order to improve clinical sensitivity.

Long-term remission and recurrence rate in a cohort of Cushing's disease: the need for long-term follow-up

OBJECTIVE

Transsphenoidal surgery is the procedure of choice in Cushing disease (CD), with immediate post-operative remission rates ranging between 59 and 94% and recurrence rates between 3 and 46%, both depending upon the definition criteria and the duration of the follow-up. Our aim was to assess the rate of remission, recurrence and persistence of the disease after the first treatment and to identify predictors of remission in the CD population of our center.

METHODS

Retrospective cohort study of the patients diagnosed of CD and with follow-up in our center between 1974 and 2011. We analyzed 41 patients (35 women and 6 men) with a mean age at diagnosis of 34 ± 13 years. The mean follow-up was 14 ± 10 years (range 1-37 years) and the median of follow-up period was 6.68 years.

RESULTS

Thirty-five (85.4%) patients underwent transsphenoidal surgery as first treatment option. Histopathological evidence of a pituitary adenoma was registered in 17 (48.5%) patients. Thirty-two (78%) patients achieved disease remission after the first treatment, 21 (65.6%) of them presented disease recurrence. Persistent disease was observed in 9 (22%) patients. Twelve (29.3%) subjects developed post-surgical adrenal insufficiency, 7 of which (70%) achieved stable remission. Two parameters were found to be significant predictors of remission after the first treatment: age at disease diagnosis and the development of adrenal insufficiency (cortisol <3 μg/dl) in the immediate post-operative state.

CONCLUSIONS

We report a high recurrence rate, at least partially attributable to the long follow-up time. Early post-surgery adrenal insufficiency predicts remission. Hypopituitarism was also very prevalent, and strongly associated with radiotherapy. These results lead us to the conclusion that CD needs a life-long strict follow-up.

Pacing strategies during repeated maximal voluntary contractions

PURPOSE

Pacing strategies have been reported to occur during continuous cyclical exercises. However, currently no studies have examined if pacing takes place during repeated maximal voluntary muscle contractions (MVCs). Accordingly, the purpose of this study was to examine if informing subjects on the number of MVCs they would perform would affect force and root mean squared electromyography (EMG), during similar fatiguing protocols.

METHODS

Thirty well-trained male subjects completed three fatiguing protocols in a randomized order. In the control condition participants were informed they would perform 12 MVCs, and then completed all 12. In the unknown condition they were not told how many MVCs they would perform, but were stopped after 12. Lastly, in the deception condition they were initially told they would perform only 6 MVCs, but after the 6 contractions they were asked to perform a few more repetitions and were stopped after 12.

RESULTS

Compared to the unknown condition, subjects demonstrated greater forces (p < 0.05, ES = 0.35-1.14, 2-7.5%) and biceps EMG (p < 0.05, ES = 0.6, 6%) in the deception condition during the first six MVCs. Additionally, under all conditions subjects applied greater forces in the last repetition (#12) relative to the previous one (#11) (p < 0.06, ES = 0.36-0.5, 2.8-3.8%).

CONCLUSIONS

The anticipation of performing a certain number of MVCs led the subjects to utilize different pacing strategies. The results also question the assumption that subjects followed the instruction to exert maximal effort during repeated MVCs.

Quality improvement needed in quality improvement randomised trials: systematic review of interventions to improve care in diabetes

OBJECTIVE

Despite the increasing numbers of published trials of quality improvement (QI) interventions in diabetes, little is known about the risk of bias in this literature.

DESIGN

Secondary analysis of a systematic review.

DATA SOURCES

Medline, the Cochrane Effective Practice and Organisation of Care (EPOC) database (from inception to July 2010) and references of included studies.

ELIGIBILITY CRITERIA

Randomised trials assessing 11 predefined QI strategies or financial incentives targeting health systems, healthcare professionals or patients to improve the management of adult outpatients with diabetes.

ANALYSIS

Risk of bias (low, unclear or high) was assessed for the 142 trials in the review across nine domains using the EPOC version of the Cochrane Risk of Bias Tool. We used Cochran-Armitage tests for trends to evaluate the improvement over time.

RESULTS

There was no significant improvement over time in any of the risk of bias domains. Attrition bias (loss to follow-up) was the most common source of bias, with 24 trials (17%) having high risk of bias due to incomplete outcome data. Overall, 69 trials (49%) had at least one domain with high risk of bias. Inadequate reporting frequently hampered the risk of bias assessment: allocation sequence was unclear in 82 trials (58%) and allocation concealment was unclear in 78 trials (55%). There were significant reductions neither in the proportions of studies at high risk of bias over time nor in the adequacy of reporting of risk of bias domains.

CONCLUSIONS

Nearly half of the included QI trials in this review were judged to have high risk of bias. Such trials have serious limitations that put the findings in question and therefore inhibit evidence-based QI. There is a need to limit the potential for bias when conducting QI trials and improve the quality of reporting of QI trials so that stakeholders have adequate evidence for implementation.

Efficacy and safety of long term treatment of unresponsive hypoparathyroidism using multipulse subcutaneous infusion of teriparatide

Vitamin D nonresponsive hypoparathyroidism is uncommonly seen in the clinical practice. The use of new treatment modalities, including teriparatide administration, provides an alternative requiring its validation. We report the first case of hypoparathyroidism refractory to vitamin D that was successfully controlled for 5 years by teriparatide treatment. A 53-year-old woman presented severe hypoparathyroidism after thyroidectomy. No therapeutic response was obtained with oral and i. v. calcium and magnesium, or even with 5 μg calcitriol/day. Digestive disorders were ruled out and heterologous parathyroid transplant was ineffective. Subcutaneous (s. c.) recombinant human PTH 1-34 (rhPTH-teriparatide) plus oral calcitriol, calcium, and magnesium, were partially effective, but effectiveness of 20 μg teriparatide lasted less than 4 h and stable calcemia was not possible even with 4-6 injections/day. Multipulse s. c. pump driven infusion of teriparatide achieved complete normalization of serum calcium, phosphate, magnesium, calciuria, and magnesuria with relatively low teriparatide doses (25-35 μg/day) after the first day of treatment. Effectiveness of this treatment modality was maintained for 5 years. The only significant side effect observed during these years was the development of subcutaneous nodules with occasional insufficient control of calcemia. A gain in bone mineral density was observed after the first year of treatment, which had remained stable and within normal values, thereafter until now. No abnormalities in bone scintigraphy were detected in the follow-up. Vitamin D unresponsive hypoparathyroidism maybe safely and effectively controlled at long term by s. c. multipulse pump treatment recombinant human PTH.

Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis

BACKGROUND

The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA(1c)), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes.

METHODS

We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias.

FINDINGS

We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84,865 patients, and 94 patient randomised controlled trials, including 38,664 patients. In random effects meta-analysis, the QI strategies reduced HbA(1c) by a mean difference of 0·37% (95% CI 0·28-0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05-0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19-4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95-2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA(1c), 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA(1c) control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21-1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01-1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13-1·32), renal function (14 trials; RR 128, 1·13-1·44), and foot abnormalities (22 trials; RR 1·27, 1·16-1·39). However, statin use (ten trials; RR 1·12, 0·99-1·28), hypertension control (18 trials; RR 1·01, 0·96-1·07), and smoking cessation (13 trials; RR 1·13, 0·99-1·29) were not significantly increased.

INTERPRETATION

Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA(1c) control is poor.

FUNDING

Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates--Health Solutions).

The efficacy of octreotide LAR as firstline therapy for patients with newly diagnosed acromegaly is independent of tumor extension: predictive factors of tumor and biochemical response

Surgical outcome of acromegaly depends on the preoperatory tumor size and extension. Somatostatin analogues are also a highly effective treatment for acromegalic patients. Nevertheless, the response of GH-secreting adenomas to primary medical therapy is variable. The aim of the present study was to evaluate the efficacy of octreotide LAR as primary therapy for acromegalic patients as a function of initial tumor extension. We performed a multicentre, prospective, observational and analytical study recruiting 19 "naive" acromegalic patients (5 microadenomas, 10 intrasellar, and 4 extrasellar macroadenomas). All of them were treated with octreotide LAR for 12 months. Basal GH and fasting IGF-I concentrations, and tumor volume were measured at baseline and after 6 and 12 months of treatment. Six patients withdrew the study. The patients who completed the protocol showed a significant reduction of tumor volume (25+/-23%, Wilk's lambda=0.506, F=4.400, p=0.046) independently of tumor extension at study entry (Wilk's lambda=0.826, F=0.452, p=0.769). A shrinkage >25% of baseline tumor volume was achieved in 8 (42%) patients with no differences between tumor extension subgroups. Basal GH levels (76+/-18%) and fasting IGF-I (52+/-31%) decreased throughout the study. Six (46%) patients normalized their IGF-I levels. Octreotide LAR is an effective first-line treatment for a large group of acromegalic patients independent of initial tumor extension.

Effectiveness of retinoic acid treatment for redifferentiation of thyroid cancer in relation to recovery of radioiodine uptake

BACKGROUND

Retinoic acid (RA) treatment has been used for redifferentiation of metastatic thyroid neoplasia that have lost radioiodine (131I) uptake with heterogeneous results.

AIM

Retrospective analysis of the recovery rate of 131I uptake after RA treatment in patients from 11 Spanish hospitals.

METHODS

Twenty-seven patients (14 men, 13 women) with papillary [21], follicular [4], and oncocytic [2] thyroid cancer initially treated with total thyroidectomy plus 131I, and with 131I negative metastatic disease, were given 13-cis RA (0.66-1.5 mg/kg for 5-12 weeks) followed by a therapeutic 131I dose (3700-7400 MBq); 3 months later thyroglobulin levels and computed tomography imaging were performed.

RESULTS

In 9 out 27 cases (33%) (8 papillary, 1 follicular) optimal positive 131I scan was observed after RA treatment; in the remaining 18, 10 had a suboptimal uptake (7 papillary, 2 follicular, 1 oncocytic) and in the rest there was no 131I uptake recovery (6 papillary, 1 follicular, 1 oncocytic). In 17 positive responses to RA (either optimal or suboptimal) in which image follow-up was available, decrease or stabilization of metastatic growth was observed in 7, while tumor mass increased at short term in the remaining 10. No major side effects were detected.

CONCLUSION

Quite a high rate of 131I uptake recovery after RA treatment may be obtained in advanced differentiated thyroid cancer, but the potential modification of the natural course of the disease is uncertain. A better biological characterization of these tumors allowing the identification of potential responders to RA may improve the outcome of RA coadjuvant therapy.

A short acute octreotide test for response prediction of long-term treatment with somatostatin analogues in acromegalic patients

The usefulness of the acute octreotide test in the selection of acromegalic patients for chronic somatostatin depot analogues treatment is controversial. The aim of the present study was to determine its accuracy for chronic response prediction, and the reliability of a short version of the classic 6-hour test. The data from 26 acromegalics (19 women, 7 men, mean age 52.6+/-13.1 years) studied with an acute octreotide test (6 hours sampling for GH measurement after octreotide 100 microg s. c.) were retrospectively analyzed. Eighteen of them followed chronic somatostatin depot analogues treatment for 12 months. GH nadir was always detected at 2 hours (mean decrease 75.9+/-24%). GH levels at 2 hours positively correlated with the other time-points (r(s) 0.97, 0.98, 0.97, 0.96 at 3, 4, 5 and 6 h, respectively; p<0.0001). During chronic treatment with maximal effective dose for 12 months, 61% of the patients achieved IGF1 <3 SD and 22% reached IGF1 <2 SD. GH nadir correlated with IGF1 decrease at 12 months (r(s) 0.76, p<0001). GH nadir of 9.2 ng/ml predicts IGF1 <3 SD with 82% sensitivity and 58% specificity (75% PPV, 67% NPV); for IGF1<2 SD, 75% sensitivity and 58% specificity are obtained for GH nadir 3.6 ng/ml, with 33% PPV and 89% NPV. Acute octreotide test reliably predicts response to long-term treatment; the short, 2-hour version is fully informative for therapeutic decisions in acromegalic patients.

Physical fitness and adolescence

Children, adolescents and adults all benefit from physical exercise and physical fitness can also bring well-being to the person. Tracking physical fitness and activity over time from childhood, adolescence into adulthood will provide information on the benefits and also increase over knowledge on intervention and intervention programs. Many children and adolescents participate in physical activity, but this activity decline in adulthood. This short review provide information from several studies on the benefit of physical exercise and fitness through childhood, adolescence into early adulthood.

Health policy for persons with intellectual disability: experiences from Israel

Intellectual disability (ID) is a life-long disability characterized by impaired cognitive and adaptive skills. Over the past few decades, a shift has occurred in the conceptualization and treatment of people with ID and research in health policy and health-care delivery has become increasingly global with a notable disparity between the developed and developing world. This review presents a literature overview of global health policy for ID with the intent to focus specifically on the policy and treatment within Israel. The methodology involved sites visits to care centers, discussions with stakeholders in health policy, and a literature review. We believe that Israel is in a unique position between a developed and developing culture. In particular, the distinct problems faced by the Arab and Bedouin community in terms of ID must be formally accounted for in Israel's future policies. Research from the developing world would be instructive to this end. The global approach in this presentation led to certain policy recommendations that take into account the uniqueness of Israel's position from a social, economic, religious, and demographic perspective. It is the hope that this paper will lead to an increased awareness of the challenges faced by persons with ID and their providers in all sectors of Israeli society and that the necessary policy recommendations will ultimately be adopted.

Acromegaly Quality of Life Questionnaire (ACROQOL) a new health-related quality of life questionnaire for patients with acromegaly: development and psychometric properties

OBJECTIVE

To develop a disease-specific questionnaire suitable to measure health-related quality of life (HRQOL) in acromegaly (ACROQOL).

DESIGN, PATIENTS AND MEASUREMENTS

For the development of the ACROQOL questionnaire different sources of information were used: First, a literature search was performed to identify relevant papers describing the impact of acromegaly in HRQOL. Second, 10 endocrinologists identified the main domains of impact on HRQOL in patients with acromegaly. Third, 10 in-depth, semistructured interviews were conducted in acromegalic patients to identify domains and items related to the self-perceived impact of acromegaly in patients' life. Qualitative analyses of the information were performed identifying domains and items to be included in the questionnaire. Those items considered ambiguous, complicated to read, double-barrelled, with jargon terms, too long, or negatively worded were excluded. Each remaining item was subsequently rated by the same panel of endocrinologists and experts in HRQOL evaluation, and assessed according to clarity of wording, frequency of occurrence and importance among patients with acromegaly. Analysis of internal consistency of the questionnaire was evaluated with a Cronbach's Alpha. A preliminary questionnaire was administered to 72 patients with acromegaly. Rasch analysis (dichotomous logistic response model) of the answers given by these patients allowed parameter estimates and model data fit indices to be computed and misfitting items deleted. Frequency of occurrence and degree of agreement with the statements were selected as response choices in a 5-point Likert type scale.

RESULTS

The following domains related to HRQOL in acromegaly were identified: physical and psychological functions, social, daily activities, symptoms, cognition, general health perception, sleep, sexual function, pain, energy and body image. An initial set of 204 expressions were identified from the initial transcripts of the patient interviews. After elimination of ambiguous or unclear expressions, 142 items remained drafted in question form. From the quantitative analysis of the item rank position within each of the three areas of clarity, frequency and importance, the 38-item questionnaire was produced, with satisfactory internal consistency (Cronbach's Alpha 0.94). Rasch analysis produced a further reduction to the final 22-item questionnaire (Cronbach's Alpha 0.91) containing two scales that evaluate physical (eight questions) and psychological aspects related to appearance and personal relations (seven items each). The evaluation of the item parameters confirmed the construct validity of the new instrument. The substantial reliability of the questionnaire suggested the sample was well targeted by the questionnaire. The initial Spanish version was translated into English and presented to five English-speaking Australian patients with acromegaly to assess and correct for comprehension, clarity, cultural relevance and suitable wording.

CONCLUSIONS

We present the ACROQOL questionnaire, developed and preliminarily validated to specifically assess HRQOL in patients with acromegaly.