Diabetic Medicine最新文献

Aim

Type 2 diabetes (T2D) in pregnancy is increasingly common and associated with suboptimal outcomes for these women and their children. We aimed to synthesize observational evidence on associations of modifiable preconception, pregnancy and postpartum risk factors with perinatal outcomes among women with pregestational T2D.

Methods

Searches were conducted in six databases (September 2023). Observational studies among women with pregestational T2D were included if they reported associations of modifiable risk factors with maternal and/or child outcomes. Screening, data extraction and quality assessments were conducted by two reviewers. Findings were synthesized through random effects meta-analysis or narrative synthesis when results were too few or heterogeneous to pool.

Results

Searches identified 15,578 results; 58 studies were included. Meta-analysis showed excessive gestational weight gain (GWG) was associated with large for gestational age (LGA) (OR 2.39, 95%CI 1.74–3.29) but not small for gestational age (SGA). Meta-analysis demonstrated no associations between preconception care or metformin use with adverse pregnancy, birth and neonatal outcomes. However, narrative synthesis showed preconception care was associated with increased use of folic acid and vitamin D, and reduced GWG. Further narrative synthesis findings showed that higher BMI was associated with multiple suboptimal pregnancy, birth and neonatal outcomes. Excessive GWG was associated with increased insulin requirements and increased likelihood of neonatal hypoglycaemia. The use of metformin/oral hypoglycaemic medications was associated with reduced GWG and fewer caesarean deliveries. There was mixed or no evidence of association for other reported exposures and outcomes.

Conclusion

Based on observational evidence, increasing access to preconception care could be beneficial to optimize maternal nutrition and weight-related outcomes, and addressing obesity and GWG has the potential to improve maternal and neonatal outcomes in pregnancies affected by T2D.

Aims

This systematic review and meta-analysis assessed the safety and efficacy of metformin in managing gestational diabetes mellitus (GDM), focusing on maternal, neonatal and long-term outcomes. While lifestyle changes are first-line treatment, pharmacological therapy is often required. Insulin, the standard, has drawbacks including weight gain, neonatal hypoglycaemia and maternal anxiety. Metformin is a promising alternative due to its insulin-sensitizing effects, but concerns remain about placental transfer and long-term effects on offspring.

Methods

A systematic search was conducted in PubMed and Embase up to 29 August 2024, including randomized controlled trials (RCTs) and follow-up studies. Primary outcomes were neonatal hypoglycaemia, birthweight and long-term metabolic outcomes. Study quality was assessed using RoB 2.0 and ROBINS-I. Data were synthesized using the IVhet model.

Results

Ten RCTs were included. Metformin was associated with a statistically significant reduction in neonatal hypoglycaemia (OR: 0.65, 95% CI: 0.46–0.92) and lower birthweight (MD: −68.96 g, 95% CI: −108.34 to −29.57). A non-significant trend towards reduced LGA risk was observed. No significant differences in prediabetes, diabetes or insulin resistance were found.

Long-term outcomes in children remain uncertain due to limited and heterogeneous follow-up data.

Conclusions

Metformin appears safe and effective in GDM management, but more data are needed on long-term outcomes.

Aims

Efforts to achieve type 2 diabetes (T2D) remission by weight loss using low-calorie diets are gaining momentum, mainly in high-income countries. The HoDiRECT Nepal project demonstrated the feasibility of a low-calorie traditional Nepali diet for diabetes remission. This qualitative substudy explored the factors affecting its implementation.

Methods

HoDiRECT participants who had completed 8 weeks of a low-calorie diet were invited to participate in one-to-one interviews at follow-up visits. The interviews were guided by a predesigned interview protocol and conducted in Nepali. The interviews were audio recorded, transcribed verbatim and analysed using a thematic framework approach.

Results

Interviews with 16 participants confirmed general acceptability of the intervention. Participants' motivation to enrol in the programme was driven by their desire to stop taking diabetes medications, achieve better diabetes control and lose weight. Understanding diabetes, its complications and the perceived value of diet influenced their decision to adhere to the programme. Adherence was facilitated by the ability to prepare food or have someone to do so, clear information about the diet and continued guidance. Participants found adherence difficult during travel and on social/cultural occasions. Healthcare professionals' involvement had a positive value, but popular beliefs, often false, about food for diabetes influenced participants' dietary behaviour.

Conclusions

Adherence to a weight-loss regimen can be enhanced if the diet is simple to prepare and if there is greater education for patients and their communities about diabetes, highlighting the effectiveness of diet as a treatment, with clear and consistent messaging about dietary practices.

Aim

Periodontitis is a chronic inflammatory oral disease characterised by the persistent activation of immune cells, which contributes to insulin resistance and, consequently, an increased risk of systemic diseases, including gestational diabetes mellitus (GDM). At the same time, the risk of periodontitis is higher in individuals with diabetes, with higher glycaemic levels being the primary contributing factor. Oral health review is also advised in diabetes care by the NICE guidelines, because of its impact on blood glucose management. However, oral health may be overlooked in GDM due to the volume of other interventions required. Furthermore, little is known about the barriers and facilitators to oral healthcare support among healthcare professionals (HCPs) working in GDM care.

To examine the barriers and facilitators to oral healthcare support among HCPs in GDM care.

Methods

The interview guide was based on the Theoretical Domains Framework (TDF), and semi-structured interviews were used for data collection. The sample consisted of UK-based HCPs with different professional backgrounds.

Results

Four barriers and three facilitators were identified. These are related to the following TDF domains: professional role and identity; beliefs about consequences; knowledge; skills; memory, attention, and decision processes; and environmental context and resources.

Conclusions

Oral health was not prioritised in GDM care. Furthermore, limited knowledge, increasing demands and time constraints, and fear of health-related information overload were barriers to oral healthcare support. Training and education to increase knowledge, perceived importance of oral health and the HCPs' role and responsibilities facilitated oral healthcare support.

Background

Inpatients with diabetes have higher early unplanned readmission (EUR) rates. Diabetes management team (DMT) review reduces EUR. While glucose-based patient selection for DMT reduces in-hospital adverse outcomes, this single criterion is a suboptimal predictor of EUR.

Aim

We developed, compared and externally validated four EUR prediction models in diabetes inpatients using primarily early admission data to facilitate timely review. Secondarily, we investigated how combining predictive and glucose data can refine patient selection for DMT review.

Methods

We constructed three traditional models (classification tree, logistic group lasso, elastic net) and a neural network model using 14 routinely available variables. Models were externally validated and performance assessed by area under the curve (AUC). We analysed the overlap between high-risk patients and those with abnormal glucose (≥1 glucose level <4 or >15 mmol/L) according to pre-specified sensitivities (25%, 50%, 75%).

Results

Group lasso, elastic net and neural network performed similarly (AUC 0.722–727 test cohort, 0.653–0.667 validation), outperforming the tree (AUC 0.663 test cohort, 0.595 validation). These models identified 9%, 21%–23% and 41%–42% of admissions as ‘high risk’ using respective sensitivities of 25%, 50% and 75%. In the group lasso, approximately half of ‘high-risk’ patients also had abnormal glucose which reduced the DMT review cohort to 4.9%, 10.8% and 19.2% for sensitivities of 25%, 50% and 75%.

Conclusion

EUR prediction models facilitate targeted, timely DMT review. Regularised regression models offer a feasible, practical approach for identifying high-risk patients in resource-limited hospital settings. Combining model-identified risk with abnormal glucose refines patient selection, optimising resource allocation.

Aims

To examine differences in pregnancy outcomes between women with type 1 (T1D) and type 2 diabetes (T2D) and assess the impact of concurrent obesity on adverse perinatal outcomes.

Materials and Methods

We retrospectively analysed singleton births of nulliparous mothers with T1D and T2D from 2016 to 2020, in New South Wales, Australia. The incidence of perinatal outcomes was compared between diabetes types. Logistic regression explored the impact of BMI and diabetes type on these outcomes, adjusting for relevant maternal characteristics.

Results

In total, 568 women with T1D and 910 women with T2D were included. Women with T2D were older, had higher BMI, increased incidence of pre-existing hypertension and smoking, and higher rates of socioeconomic disadvantage (p < 0.01). After stepwise adjustment for maternal covariates, women with T1D had higher odds of preeclampsia, caesarean section, maternal length of stay (LOS) >10 days, preterm birth, large-for-gestational age (LGA) neonates, neonatal resuscitation, neonatal hypoglycaemia, NICU admission, neonatal LOS >10 days and stillbirth (aOR >1, p < 0.05). Obesity conferred an increased odds of adverse outcomes in women with T2D but not T1D; these included gestational hypertension (aOR = 5.88, CI:1.38–25.15, p = 0.02), postpartum haemorrhage (aOR = 1.95, CI:1.18–3.23, p < 0.01), caesarean section (aOR = 2.29, CI:1.59–3.30, p < 0.01), LGA (aOR = 1.82, CI:1.13–2.93, p = 0.01), neonatal hypoglycaemia (aOR = 1.53, CI:1.02–2.30, p = 0.04) and neonatal resuscitation (aOR = 1.81, CI:1.19–2.76, p < 0.01).

Conclusion

Women with T1D had higher odds of adverse perinatal outcomes compared to those with T2D. Obesity increased risk in women with T2D, but not T1D, raising the possibility that targeted weight interventions in those with T2D may reduce the risk of adverse perinatal outcomes.

Aims

This study assesses national trends and, socio-demographic and clinical factors associated with polypharmacy and potentially in appropriate prescribing among people with type 2 diabetes in Scotland from 2012 to 2022.

Methods

Retrospective cohort study using nationwide data from the Scottish Care Information – Diabetes database. Individuals aged ≥40 years with type 2 diabetes were included. Medication counts were based on unique medications dispensed per calendar year. Potentially inappropriate medications were based on the 2023 Beers criteria and applied to people aged over 65 years. A Poisson mixed-effects model with individual-level random intercepts assessed the relationship between the number of drug classes dispensed and year, gender, age group and socio-economic status, Elixhauser comorbidity index and the hospital frailty risk score.

Results

387,338 people were included. The median number of medications dispensed per person was 9 (interquartile range 5–13). Adjusted medication counts were modestly higher in older people (rate ratio [RR] 1.06, 95% confidence interval [CI] 1.06–1.06 at age 80+ compared to 40–59), higher in women (1.14, 1.13–1.14), in more deprived areas (1.24, 1.23–1.24 in the most deprived vs. the most affluent quintile) and in those with higher comorbidity (1.12, 1.12–1.13 in 4+ vs. 0 comorbidities) but not with high frailty risk (1.00, 1.00–1.00). People over 65 were dispensed a median of 2 (IQR 1–3) potentially inappropriate medications. Potentially inappropriate medication showed a stronger association with comorbidity (1.24, 1.23–1.25) and a positive association with high frailty risk (1.24, 1.23–1.25).

Conclusions

The degree of polypharmacy highlights the need for regular formal medication reviews in this population.

Aims

To evaluate the impact of obesity, with or without gestational diabetes mellitus (GDM), on adverse maternal outcomes and determine whether the combination of obesity and GDM confers a greater risk compared to obesity alone.

Methods

We systematically searched MEDLINE, EMBASE, Scopus, CINAHL and the WoS Core Collection, identifying 19 studies. Pooled estimates (odds ratios, OR and mean differences, MD) with 95% confidence intervals (CI) were calculated using random effects models.

Results

Obesity alone significantly increased the risk of caesarean section (OR 2.63, 95% CI 1.40–4.94), pre-eclampsia (OR 3.09, 95% CI 2.35–4.07), induction of labour (OR 1.73, 95% CI 1.58–1.90) and postpartum haemorrhage (OR 1.35, 95% CI 1.01–1.81) compared to normal-weight, non-GDM women. GDM alone also increased the risk of caesarean section (OR 1.66, 95% CI 1.28–2.15) and pre-eclampsia (OR 1.57, 95% CI 1.21–2.04), though to a lesser extent. Combined, obesity and GDM markedly elevated risks, with a four-fold increase in caesarean section (OR 4.26, 95% CI 1.57–11.53) and pre-eclampsia (OR 4.07, 95% CI 2.90–5.71), and a sixfold increase for induction of labour (OR 6.44, 95% CI 1.25–24.63). Comparatively, obesity alone conferred a higher risk for caesarean section and pre-eclampsia than GDM alone (OR 1.45, 95% CI 1.03–2.03 and OR 2.15, 95% CI 1.50–3.09, respectively). No significant differences were observed for instrumental delivery rates.

Conclusions

Obesity contributes significantly to adverse maternal outcomes, conferring a greater risk for caesarean section and pre-eclampsia than GDM alone. The combination of obesity and GDM amplifies these risks, underscoring the need to prioritise obesity management as a distinct focus in pregnancy care.

Aims

Type 1 diabetes is an autoimmune condition in which the presymptomatic stages are detectable through screening and monitoring programmes. These are being rolled out across Australia and internationally. However, little is known about healthcare professionals' knowledge requirements in the context of paediatric screening and monitoring of early-stage type 1 diabetes.

Methods

We interviewed 32 purposively sampled Australian healthcare professionals, involved in early-stage or clinical type 1 diabetes care, about their perspectives and experiences of knowledge regarding paediatric screening and monitoring of early-stage type 1 diabetes. This study forms part of the Qualitative experiences of Early-Stage Type 1 diabetes (QuEST) project. Data were analysed using reflexive thematic analysis.

Results

Four themes were generated: (1) Varied Ways of Developing Knowledge; (2) Desire for Enhanced Knowledge; (3) Need for Far-Reaching Education; and (4) Knowing How to Meet Families' Psychological Needs. Participants described engaging in ongoing self-directed and peer-based learning, while also seeking formal education. They sought knowledge on monitoring procedures, type 1 diabetes risk prediction and communicating with families. Participants also desired guidance on supporting families emotionally within their scope of practice.

Conclusions

These findings highlight priority areas for healthcare professional education, particularly as screening and monitoring programmes for early-stage type 1 diabetes expand. Clear guidance and training for healthcare professionals working in early-stage and clinical type 1 diabetes management are essential, followed by an evaluation of their knowledge after implementing learning strategies informed by our findings.