The risk stratification of adverse neonatal outcomes in women with gestational diabetes (STRONG) study

Aims: To assess the risk of adverse neonatal outcomes in women with gestational diabetes (GDM) by identifying subgroups of women at higher risk to recognize the characteristics most associated with an excess of risk. Methods: Observational, retrospective, multicenter study involving consecutive women with GDM. To identify distinct and homogeneous subgroups of women at a higher risk, the RECursive Partitioning and AMalgamation (RECPAM) method was used. Overall, 2736 pregnancies complicated by GDM were analyzed. The main outcome measure was the occurrence of adverse neonatal outcomes in pregnancies complicated by GDM. Results: Among study participants (median age 36.8 years, pre-gestational BMI 24.8 kg/m2), six miscarriages, one neonatal death, but no maternal death was recorded. The occurrence of the cumulative adverse outcome (OR 2.48, 95% CI 1.59–3.87), large for gestational age (OR 3.99, 95% CI 2.40–6.63), fetal malformation (OR 2.66, 95% CI 1.00–7.18), and respiratory distress (OR 4.33, 95% CI 1.33–14.12) was associated with previous macrosomia. Large for gestational age was also associated with obesity (OR 1.46, 95% CI 1.00–2.15). Small for gestational age was associated with first trimester glucose levels (OR 1.96, 95% CI 1.04–3.69). Neonatal hypoglycemia was associated with overweight (OR 1.52, 95% CI 1.02–2.27) and obesity (OR 1.62, 95% CI 1.04–2.51). The RECPAM analysis identified high-risk subgroups mainly characterized by high pre-pregnancy BMI (OR 1.68, 95% CI 1.21–2.33 for obese; OR 1.38 95% CI 1.03–1.87 for overweight). Conclusions: A deep investigation on the factors associated with adverse neonatal outcomes requires a risk stratification. In particular, great attention must be paid to the prevention and treatment of obesity

A Multicenter Retrospective Survey regarding Diabetic Ketoacidosis Management in Italian Children with Type 1 Diabetes

We conducted a retrospective survey in pediatric centers belonging to the Italian Society for Pediatric Diabetology and Endocrinology. The following data were collected for all new-onset diabetes patients aged 0-18 years: DKA (pH < 7.30), severe DKA (pH < 7.1), DKA in preschool children, DKA treatment according to ISPAD protocol, type of rehydrating solution used, bicarbonates use, and amount of insulin infused. Records (n = 2453) of children with newly diagnosed diabetes were collected from 68/77 centers (87%), 39 of which are tertiary referral centers, the majority of whom (n = 1536, 89.4%) were diagnosed in the tertiary referral centers. DKA was observed in 38.5% and severe DKA in 10.3%. Considering preschool children, DKA was observed in 72%, and severe DKA in 16.7%. Cerebral edema following DKA treatment was observed in 5 (0.5%). DKA treatment according to ISPAD guidelines was adopted in 68% of the centers. In the first 2 hours, rehydration was started with normal saline in all centers, but with different amount. Bicarbonate was quite never been used. Insulin was infused starting from third hour at the rate of 0.05-0.1 U/kg/h in 72% of centers. Despite prevention campaign, DKA is still observed in Italian children at onset, with significant variability in DKA treatment, underlying the need to share guidelines among centers

The use of a hybrid mannequin for the modern high-fidelity simulation in the labor ward: the Italian experience of the Ecografia Gestione Emergenze Ostetriche (EGEO) group

Regular training in the management of intrapartum emergencies has been demonstrated to yield measurable benefits in terms of maternal and perinatal outcomes. Thanks to technologic advances, computerized, full-body mannequins have been created and made available for high-fidelity simulation in obstetrics. The technical skills subjected to training are conventionally represented by classical manual maneuvers, which are recommended in the case of instrumental vaginal delivery, shoulder dystocia, or postpartum hemorrhage. During the past few years, manual skills in the labor ward have been increasingly supported by the use of ultrasound, and this has substantially altered the practical management of intrapartum emergencies in real life. Based on this, a new generation of mannequins suitable for both clinical maneuvers and ultrasound examination seems to be the most appropriate tool for the modern high-fidelity simulation in the management of intrapartum complications. The use of these new hybrid clinical ultrasound mannequins may usher in a new era in high-fidelity obstetric simulation and can hopefully optimize the competencies and technical skills of labor ward professionals in the management of obstetric emergencies. It is from this background that at the beginning of 2018, the Ecografia Gestione Emergenze Ostetriche group was founded in Italy. This group has aggregated a multiprofessional labor ward team including obstetricians, midwives, and anesthesiologists under the common philosophy that ultrasound provides an essential added value in the management of obstetric emergencies. Thanks to the use of these mannequins, the multiprofessional Italian Ecografia Gestione Emergenze Ostetriche group has started to run practical workshops to promote the culture of extraordinary synergy of ultrasound and clinical skills as the best approach to handle intrapartum complications

A 1-year long-term study on efficacy and safety of degludec in children and adolescents with type 1 diabetes

Objectives: Degludec (IDeg) seems to improve glycemic control and to prevent hypoglycemia, respect to glargine (IGlar), in patients with type 1 diabetes (T1D). Few data have been published on IDeg effects in childhood. The aim of our study was to assess 1-year efficacy and safety of IDeg as a part of a basal-bolus (BB) therapy in children and adolescents with T1D. Methods: Forty patients (12.34.55 yrs; 24 males; 19 prepubertal; T1D duration 5.353.78 yrs; IGlar treatment by at least 1 year) were switched to once-daily IDeg because of HbA1c >7.5% or pain at IGlar injection. Insulin dose [IGlar or IDeg plus short-acting/regular at mealtime (MT)], HbA1c, FPG, BMI z-score, and severe hypoglycaemia rates were collected at baseline (T0), 3-months (T1), 6-months (T2), and 12-months (T3) after IDeg was started. Results: The switch from IGlar to IDeg allowed a longitudinal decreased of BB dose (median Δ% -3.28 at T0, -5.02 at T1, -5.36 at T2, and -4.26 at T3; ANOVA Chi Sqr.=10.4, p=0.033) mainly due to the reduction of MT dose (median Δ% -0.00 at T0, -6.06 at T1, -5.90 at T2, and -10.7 at T3; ANOVA Chi Sqr.=18.7, p7.5% at T0 (21 subjects) we found a longitudinal decrease in HbA1c values from 8.4% to 7.8 at T1 (p=0.005), 7.9 at T2 (p=0.031), and 8.0 at T3 (p=0.086). Moreover, 8 out 21 had HbA1c < 7.5% at T3. FPG improved by 9.5% at T2 and 3.3% at T3. BMI z-score did not change and no episode of severe hypoglycaemia was reported. Conclusions: IDeg seems to improve the glycemic control than therapy with IGlar, mainly in patients with poor glycemic control. Our results in children and adolescents suggest that the dose of IDeg should not be reduced and the MT bolus insulin appropriate replacement doses should be lowered by 11% for patients who previously received IGlar. IDeg might be considered a useful and well tolerated basal insulin also in childhood