Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews

Background Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies. Objectives To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. Methods We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded. Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data. Main results We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM. Effective Lifestyle versus usual care Lifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality). Promising No evidence for any outcome for any comparison could be classified to this category. Ineffective or possibly harmful Lifestyle versus usual care Lifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality). Exercise versus control Exercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality). Insulin versus oral therapy Insulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality). Probably ineffective or harmful interventions Insulin versus oral therapy For insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality). Inconclusive Lifestyle versus usual care The evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality). Exercise versus control The evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality). Insulin versus oral therapy The evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes. Insulin versus diet The evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality). Insulin versus insulin The evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality). No conclusions possible No conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low quality. Authors’ conclusions Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed

Takotsubo syndrome in a Sardinian amyotrophic lateral sclerosis cohort

IntroductionAmyotrophic lateral sclerosis (ALS) is known to be associated with varying degrees of autonomic and cardiovascular dysfunction. Recent case reports showed that ALS may be linked to Takotsubo syndrome (TTS). We assessed the frequency of TTS in an incident ALS cohort from Sardinia, Italy, and investigated the relationship of TTS with ALS course.MethodsWe retrospectively examined a 10-year (2010-2019) incident cohort of ALS patients of Sardinian ancestry, reported TTS frequency and patients' clinical characteristics. Following, we checked for TTS among patients with ALS onset after 2019 and focused on the same features as for the incident cohort.ResultsOur incident cohort included 344 ALS patients and 5 of them (1.45%) developed TTS. All were female and their median onset age was 71.5 years (IQR 62.75-77). Two patients had spinal and three bulbar onset, though all patients had bulbar involvement and were at an advanced stage of disease (ALSFRS <= 25, King's >= 3) at TTS diagnosis. We identified a potential TTS trigger in three patients (hospitalization for PEG placement, pneumonia). Among patients who had ALS onset after 2019, we identified a further TTS case and described it.ConclusionTTS is not a rare condition in ALS. Female sex, bulbar involvement, and later age of disease onset may be important risk factors for developing this cardiac condition and a physical or psychological trigger is often observed. Despite autonomic dysfunction in ALS has been already demonstrated, the precise physiopathological mechanism underlying TTS needs to be further clarified

The near-infrared imager and slitless spectrograph for the James Webb Space Telescope. II. Wide field slitless spectroscopy

We acknowledge support from the Natural Sciences and Engineering Research Council of Canada (NSERC) through a variety of its funding programs. This work is in part supported by Canadian Space Agency grant 18JWSTGTO1. C.P., S.R. and K.V. are supported by the Canadian Space Agency under a contract with NRC Herzberg Astronomy and Astrophysics. K.M. acknowledges funding by the Science and Technology Foundation of Portugal (FCT), grants No. IF/00194/2015, PTDC/FIS-AST/28731/2017, UIDB/00099/2020.We present the wide field slitless spectroscopy mode of the NIRISS instrument on the James Webb Space Telescope. This mode employs two orthogonal low-resolution (resolving power ≈150) grisms in combination with a set of six blocking filters in the wavelength range 0.8–2.3 μm to provide a spectrum of almost every source across the field-of-view. When combined with the low background, high sensitivity and high spatial resolution afforded by the telescope, this mode will enable unprecedented studies of the structure and evolution of distant galaxies. We describe the performance of the as-built hardware relevant to this mode and expected imaging and spectroscopic sensitivity. We discuss operational and calibration procedures to obtain the highest quality data. As examples of the observing mode usage, we present details of two planned Guaranteed Time Observations programs: The Canadian NIRISS Unbiased Cluster Survey and The NIRISS Survey for Young Brown Dwarfs and Rogue Planets.Publisher PDFPeer reviewe

Survey of knowledge and perception on the access to evidence-based practice and clinical practice change among maternal and infant health practitioners in South East Asia

Background Evidence-based practice (EBP) can provide appropriate care for women and their babies; however implementation of EBP requires health professionals to have access to knowledge, the ability to interpret health care information and then strategies to apply care. The aim of this survey was to assess current knowledge of evidence-based practice, information seeking practices, perceptions and potential enablers and barriers to clinical practice change among maternal and infant health practitioners in South East Asia. Methods Questionnaires about IT access for health information and evidence-based practice were administered during August to December 2005 to health care professionals working at the nine hospitals participating in the South East Asia Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project in Indonesia, Malaysia, Thailand and The Philippines. Results The survey was completed by 660 staff from six health professional groups. Overall, easy IT access for health care information was available to 46% of participants. However, over a fifth reported no IT access was available and over half of nurses and midwives never used IT health information. Evidence-based practice had been heard of by 58% but the majority did not understand the concept. The most frequent sites accessed were Google and PubMed. The Cochrane Library had been heard of by 47% of whom 51% had access although the majority did not use it or used it less than monthly. Only 27% had heard of the WHO Reproductive Health Library and 35% had been involved in a clinical practice change and were able to identify enablers and barriers to change. Only a third of participants had been actively involved in practice change with wide variation between the countries. Willingness to participate in professional development workshops on evidence-based practice was high. Conclusion This survey has identified the need to improve IT access to health care information and health professionals' knowledge of evidence-based health care to assist in employing evidence base practice effectively.Ruth Martis, Jacqueline J Ho and Caroline A Crowther for The SEA-ORCHID Study Grou

A 4-gigabase physical map unlocks the structure and evolution of the complex genome of Aegilops tauschii, the wheat D-genome progenitor

The current limitations in genome sequencing technology require the construction of physical maps for high-quality draft sequences of large plant genomes, such as that of Aegilops tauschii, the wheat D-genome progenitor. To construct a physical map of the Ae. tauschii genome, we fingerprinted 461,706 bacterial artificial chromosome clones, assembled contigs, designed a 10K Ae. tauschii Infinium SNP array, constructed a 7,185-marker genetic map, and anchored on the map contigs totaling 4.03 Gb. Using whole genome shotgun reads, we extended the SNP marker sequences and found 17,093 genes and gene fragments. We showed that collinearity of the Ae. tauschii genes with Brachypodium distachyon, rice, and sorghum decreased with phylogenetic distance and that structural genome evolution rates have been high across all investigated lineages in subfamily Pooideae, including that of Brachypodieae. We obtained additional information about the evolution of the seven Triticeae chromosomes from 12 ancestral chromosomes and uncovered a pattern of centromere inactivation accompanying nested chromosome insertions in grasses. We showed that the density of noncollinear genes along the Ae. tauschii chromosomes positively correlates with recombination rates, suggested a cause, and showed that new genes, exemplified by disease resistance genes, are preferentially located in high-recombination chromosome regions