Diagnosis of gestational diabetes

peer reviewedGestational diabetes (GD) is a common complication of pregnancy. Its prevalence depends on the strategy used for screening and the studied population. Pregnant women with GD are at increased risk for maternal and fetal complications. The relationship between maternal blood sugar and complications is linear, without a clear threshold defining GD. Therefore, the diagnostic criteria for GD have been the subject of several controversies since many years. The choice of the one-step or two-step method, the test to be used and the cut-off levels validated to define GD are still debated. The same is true regarding a universal versus a at-risk population screening. International experts have recently proposed the use of a one-step approach with a 2-hour oral glucose tolerance test for a universal screening. The need for a better harmonization regarding the diagnosis of GD is indeed mandatory. The present article discusses both the advantages and disadvantages of the various approaches used for GD screening.Le diabète gestationnel (DG) est une complication fréquente de la grossesse. Sa prévalence varie fortement selon la stratégie de dépistage utilisée ainsi que la population étudiée. Le DG expose à un haut risque de complications, à la fois sur le plan maternel et foetal. Ces complications sont en relation directe avec l’hyperglycémie maternelle, mais cette relation est linéaire, sans valeur-seuil clairement définie. Cela explique sans doute pourquoi il est difficile d’énoncer des critères indiscutables de diagnostic du DG. De nombreuses controverses existent depuis plusieurs années dans la littérature quant aux méthodes les plus adéquates pour dépister le DG. Les questions sont relatives à l’intérêt d’une méthode en une ou deux étapes, au test à utiliser en priorité, aux valeursseuil à considérer en fonction du test retenu ainsi qu’au choix d’un dépistage universel ou uniquement ciblé sur les femmes à risque. Un groupe d’experts internationaux a proposé récemment un dépistage universel du DG avec la réalisation d’une hyperglycémie provoquée par voie orale de 2 heures. Une harmonisation des approches diagnostiques du DG est, en effet, indispensable. Cette vignette clinique discute les avantages et désavantages des différentes stratégies proposées pour dépister le DG

Poor glycaemic control in secondary care insulin treated patients correlates with bad process indicators

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Haemodynamic changes during a squat test, pulsatile stress and indices of cardiovascular autonomic neuropathy in patients with long-duration type 1 diabetes.

AIM: Cardiovascular autonomic neuropathy (CAN) and pulsatile stress are considered to be independent cardiovascular risk factors. This study compared haemodynamic changes during an active orthostatic test in adult patients with type 1 diabetes (T1DM), using low versus high RR E/I ratios as a marker of CAN. METHODS: A total of 20 T1DM patients with low RR E/I ratios were compared with 20 T1DM patients with normal RR E/I ratios, matched for gender (1/1 ratio), age (mean: 46years) and diabetes duration (22-26years); 40 matched healthy subjects served as controls. All subjects were evaluated by continuous monitoring of arterial blood pressure (Finapres((R))) and heart rate using a standardized posture test (1-min standing, 1-min squatting, 1-min standing), thus allowing calculation of baroreflex gain. RESULTS: Compared with controls, T1DM patients showed lower RR E/I ratios, reduced baroreflex gains, higher pulsatile stress (pulse pressurexheart rate), greater squatting-induced pulse pressure rises, orthostatic hypotension and reduced reflex tachycardia. Compared with T1DM patients with preserved RR E/I ratios, T1DM patients with low RR E/I ratios showed reduced post-standing reflex tachycardia and baroreflex gain, and delayed blood pressure recovery, but no markers of increased pulsatile stress. Interestingly, decreased baroreflex gain was significantly associated with both pulsatile stress and microalbuminuria. CONCLUSION: The use of RR E/I ratios to separate T1DM patients allows the detection of other CAN markers during an orthostatic posture test, but with no significant differences in pulsatile stress or microalbuminuria. In this context, squatting-derived baroreflex gain appears to be more informative.Peer reviewe

Novel Assay of Metformin Levels in Patients With Type 2 Diabetes and Varying Levels of Renal Function: Clinical recommendations

AbstractObjective: To study trough levels of metformin in serum and its intra individual variation in patients using a newly developed assay. Research Design and Methods: Trough serum levels of metformin was measured once using Liquid Chromatography Tandem Mass Spectrometry (LcMSMS) in 137 type 2 diabetes patients with varying renal function (99 men) and followed repeatedly during two months in 20 patients (16 men) with estimated GFR (eGFR) below 60 ml/min/1.73 m(2) body surface. Results: Patients with eGFR >60, 30-60, and <30 ml/min/1.73 m(2) had a median trough metformin concentration of 4.5 mumol/l (range 0.1-20.7, n=107), 7.71 mumol/l (0.12-15.15, n=21), and 8.88 mumol/l (5.99-18.60, n=9), respectively. The median intraindividual overall coefficient of variation (CV) was 29.4 % (range 9,8-74,2). Conclusions: Determination of serum metformin with the LCMSMS technique is useful in patients on metformin treatment. Few patients had values over 20 mumol/L. Metformin measurement is less suitable for dose titration

Bianchi type IX asymptotical behaviours with a massive scalar field: chaos strikes back

We use numerical integrations to study the asymptotical behaviour of a homogeneous but anisotropic Bianchi type IX model in General Relativity with a massive scalar field. As it is well known, for a Brans-Dicke theory, the asymptotical behaviour of the metric functions is ruled only by the Brans-Dicke coupling constant with respect to the value -3/2. In this paper we examine if such a condition still exists with a massive scalar field. We also show that, contrary to what occurs for a massless scalar field, the singularity oscillatory approach may exist in presence of a massive scalar field having a positive energy density.Comment: 31 pages, 7 figures (low resolution

Pulsatile Stress in Middle-Aged Patients With Type 1 or Type 2 Diabetes Compared With Nondiabetic Control Subjects

AbstractBackground: Arterial pulse pressure (PP) is considered as an independent cardiovascular risk factor. We compared PP during an active orthostatic test in middle-aged patients with type 1 diabetes and with type 2 diabetes, and corresponding nondiabetic controls. Methods: 40 patients with type 1 diabetes (mean age 50 years, diabetes duration 23 years, BMI 23.0 kg/m(2)) were compared to 40 non hypertensive patients with type 2 diabetes (respectively, 50 years, 8 years, 29.7 kg/m(2)). Patients taking antihypertensive agents or with renal insufficiency were excluded. All patients were evaluated with a continuous noninvasive arterial blood pressure monitoring (Finapres(R)) in standing (1 min), squatting (1 min) and again standing position (1 min). Patients with type 1 or type 2 diabetes were compared with two groups of 40 age-, sex- and BMI-matched healthy subjects. Results: Patients with type 1 diabetes and patients with type 2 diabetes showed significantly higher PP, heart rate (HR) and PPxHR double product (type 1 : 5263 vs 4121 mmHg/min, p=0.0004; type 2 : 5359 vs 4321 mmHg, p=0.0023) levels than corresponding controls. There were no significant differences between patients with type 1 diabetes and type 2 diabetes regarding PP (59 vs 58 mmHg), HR (89 vs 88/min), and PPxHR product (5263 vs 5359 mmHg/min). Conclusion: Patients with type 1 diabetes have comparable increased levels of peripheral PP, an indirect marker of arterial stiffness, and PPxHR, an index of pulsatile stress, as non-hypertensive patients with type 2 diabetes at similar mean age of 50 years

Symbolic Software for the Painleve Test of Nonlinear Ordinary and Partial Differential Equations

The automation of the traditional Painleve test in Mathematica is discussed. The package PainleveTest.m allows for the testing of polynomial systems of ordinary and partial differential equations which may be parameterized by arbitrary functions (or constants). Except where limited by memory, there is no restriction on the number of independent or dependent variables. The package is quite robust in determining all the possible dominant behaviors of the Laurent series solutions of the differential equation. The omission of valid dominant behaviors is a common problem in many implementations of the Painleve test, and these omissions often lead to erroneous results. Finally, our package is compared with the other available implementations of the Painleve test.Comment: Published in the Journal of Nonlinear Mathematical Physics (http://www.sm.luth.se/math/JNMP/), vol. 13(1), pp. 90-110 (Feb. 2006). The software can be downloaded at either http://www.douglasbaldwin.com or http://www.mines.edu/fs_home/wherema

TSH-Lowering Effect of Metformin in Type 2 Diabetic Patients: Differences between euthyroid, untreated hypothyroid, and euthyroid on L-T4 therapy patients

OBJECTIVE: To assess the interplay between metformin treatment and thyroid function in type 2 diabetic patients. RESEARCH DESIGN AND METHODS: The acute and long-term effects of metformin on thyroid axis hormones were assessed in diabetic patients with primary hypothyroidism who were either untreated or treated with levothyroxine (L-T4), as well as in diabetic patients with normal thyroid function. RESULTS: No acute changes were found in 11 patients with treated hypothyroidism. After 1 year of metformin administration, a significant thyrotropin (TSH) decrease (P < 0.001) was observed in diabetic subjects with hypothyroidism who were either treated (n = 29; from 2.37 +/- 1.17 to 1.41 +/- 1.21 mIU/l) or untreated (n = 18; 4.5 +/- 0.37 vs. 2.93 +/- 1.48) with L-T4, but not in 54 euthyroid subjects. No significant change in free T4 (FT4) was observed in any group. CONCLUSIONS: Metformin administration influences TSH without change of FT4 in patients with type 2 diabetes and concomitant hypothyroidism. The need for reevaluation of thyroid function in these patients within 6-12 months after starting metformin is indicated

Type 2 diabetes mellitus and osteoarthritis

Objectives: Type 2 diabetes mellitus (T2DM) and osteoarthritis (OA) are common diseases that frequently co-exist, along with overweight/obesity. While the mechanical impact of excess body weight on joints may explain lower limb OA, we sought to explore whether T2DM is linked to OA outside of excess weight and whether T2DM may play a role in OA pathophysiology. The consequence of T2DM on OA outcomes is a question of research interest. Methods: We conducted a critical review of the literature to explore the association between T2DM and OA, whether any association is site-specific for OA, and whether the presence of T2DM impacts on OA outcomes. We also reviewed the literature to assess the safety of anti-OA treatments in patients with T2DM. Results: T2DM has a pathogenic effect on OA through 2 major pathways involving oxidative stress and low-grade chronic inflammation resulting from chronic hyperglycemia and insulin resistance. T2DM is a risk factor for OA progression and has a negative impact on arthroplasty outcomes. Evidence is mounting for safety concerns with some of the most frequently prescribed anti-OA medications, including paracetamol, non-steroidal anti-inflammatory drugs, and corticosteroid injections, while other anti-OA medications may be safely prescribed in OA patients with T2DM, such as glucosamine and intra-articular hyaluronic acid. Conclusions: Future research is needed to better understand whether diabetes control and prevention can modulate OA occurrence and progression. The selection of therapy to treat OA symptoms in patients with T2DM may require careful consideration of the evidence based to avoid untoward safety issues.The meeting was funded by the ESCEO, a Belgian not-for-profit organization. The authors thank the Chair for Biomarkers of Chronic Diseases and the International Scientific Partnership Program (ISPP#0111) at King Saud University, Riyadh, Saudi Arabia for their suppor