A Single Visit Diabetes Complication Assessment Service: a Complement to Diabetes Management at the Primary Care Level

Modern diabetes management emphasizes the early detection and prompt treatment of diabetic complications. However it is difficult to organize comprehensive screening at the primary care level. To address this problem we established a complication assessment service whereby all the major diabetes-specific complications were assessed in a single 3 h visit. A report with results and recommendations was sent to the general practitioner (GP). Being philosophically a complication-specific service, no attempt was made to intervene with metabolic management. This paper describes our experience with the first 743 patients of whom 92% had been referred from GPs. Of the diabetes-specific complications, 22% of patients had one, 5% had two, and 1% had three major complications. Many of the patients were unaware of the presence of these complications. One hundred and three people had attended the service on more than one occasion with an average time between visits of 1.7 years. The results demonstrated that GPs were very good at following a recommendation to refer a patient for ophthalmic assessment (85% of cases) and improving hypertension but were less successful in treating hyperlipidaemia. This service has proven to be an excellent forum for the collection of data and the teaching of health professionals. It is a move away from the traditional format of hospital-based clinics providing comprehensive diabetes management.     

Possible sources of discrepancies in the use of the Semmes-Weinstein monofilament. Impact on prevalence of insensate foot and workload requirements

OBJECTIVE: The purpose of this study was to evaluate the effects of different testing sites and buckling strengths on the sensitivity and specificity of using the Semmes-Weinstein monofilament to detect patients with insensate foot. The impact on workload required to educate and follow up these high-risk individuals was estimated by modeling in our patient population with a documented status of neuropathy. RESEARCH DESIGN AND METHODS: Using the 5.07/10-g monofilament, one observer tested 132 randomly selected subjects with diabetes at five sites on the right foot. The sensitivity and specificity of each site and combinations of sites in detecting vibration perception threshold > 40 was calculated. In addition, two monofilaments, one with a buckling force of 5 g and the other with a force of 15 g, were compared by testing 200 randomly selected patients. An estimate of the prevalence of insensate foot and workload was made by modeling the findings to the 5,270 patients with neuropathy status registered on our computerized database. RESULTS: Specificity of the 5.07/10-g monofilament to detect insensate foot at each of the five sites is high, at approximately 90%, but there is considerably more variation and lower sensitivity, ranging from 44-71%. Data derived from the use of different combinations of sites showed that more stringent criteria are associated with lower sensitivity but higher specificity. If the foot is considered insensate when either of sites 3 and 4 (plantar aspect of the first and fifth metatarsal heads, respectively) cannot feel the monofilament, there is reasonable sensitivity and specificity (80-86%, respectively). By modeling on our diabetes center population, it can be demonstrated that the choice of different methodologies leads to different conclusions about the prevalence of severe neuropathy, ranging from 3.4 to 29.3%. CONCLUSIONS: Using a combination of sites 3 and 4 for monofilament testing gives a reasonable compromise for time, sensitivity, and specificity. Minor changes in sensitivity and specificity can lead to major changes in the prevalence of neuropathy, with implications for workload.     

Obesity,antenatal depression,diet and gestational weight gain in a population cohort study

Purpose

The aims of this paper are to examine: (1) the relationship between high pre-pregnancy BMI and antenatal depression; (2) whether BMI and antenatal depression interact to predict diet and gestational weight gain (GWG).

Methods

Data came from the Avon Longitudinal Study of Parents and Children (ALSPAC). Underweight women were excluded. Pre-pregnancy BMI was self-reported and antenatal depression was assessed using the Edinburgh Postnatal Depression Scale at 18 and 32 weeks’ gestation to identify persistently elevated depressive symptoms (EPDS>12). Dietary patterns were calculated from food frequency questionnaires at 32 weeks’ gestation. GWG was categorised using the USA Institute of Medicine guidelines.

Results

This study included 13,314 pregnant women. Obese women had significantly higher odds of antenatal depression than normal weight controls after adjusting for socio-demographics and health behaviours (aOR 1.39, 95%CI 1.05–1.84). Every unit increase in pre-pregnancy BMI was associated with approximately 3% higher odds of antenatal depression (aOR 1.03, 95%CI 1.01-1.05). Antenatal depression was not meaningfully associated with dietary patterns after adjusting for confounders and was not associated with inadequate or excessive GWG. There was no evidence for an interaction of depression and BMI on either diet or GWG.

Conclusions

Healthcare professionals should be aware of the dose-response relationship between high pre-pregnancy BMI and antenatal depression.

     

Post-bronchoscopy sputum: improving the diagnostic yield in smear negative pulmonary TB

Introduction

Patients with suspected active Pulmonary Tuberculosis (PTB) who are Acid-Fast Bacilli (AFB) smear negative or non-productive of sputum may undergo bronchoalveolar lavage. However, post-bronchoscopy sputum (PBS) sampling is not routine. The aim of this study was to establish the potential diagnostic value of PBS sampling.

Methods

A retrospective study of patients attending a London University hospital with microbiologically confirmed PTB between January 2004 and December 2010. Patients who were AFB smear negative or non-productive of sputum were eligible if sputum sampling was performed within 7 days of bronchoscopy.

Results

Over the study period, 236 patients had microbiologically confirmed smear negative PTB of which 57 patients were eligible for the study. 15 patients (26.3%) were infected with HIV. 19 patients (33.3%) converted to AFB sputum smear positivity post-bronchoscopy and 5 patients (8.8%) were exclusively AFB sputum smear positive on PBS microscopy. Mycobacterium tuberculosis was cultured from the PBS of 43 patients (75.4%) and of these, 4 (7.0%) were exclusively PBS culture positive.

Conclusion

PBS analysis can provide a simple method of rapidly diagnosing pulmonary tuberculosis. In this cohort, M. tuberculosis culture yield was increased by 7% through PBS sampling. This study has important infection control implications with nearly one third of patients becoming more infectious after bronchoscopy.     

Can Common Clinical Parameters Be Used to Identify Patients Who Will Need Insulin Treatment in Gestational Diabetes Mellitus?

OBJECTIVE

To identify patients with gestational diabetes mellitus (GDM) who will need antenatal insulin treatment (AIT) by using a risk-prediction tool based on maternal clinical and biochemical characteristics at diagnosis.

RESEARCH DESIGN AND METHODS

Data from 3,009 women attending the Royal Prince Alfred Hospital GDM Clinic, Australia, between 1995 and 2010 were studied. A risk engine was developed from significant factors identified for AIT using a logistic regression model.

RESULTS

A total of 51% of GDM patients required AIT. Ethnicity, gestation at diagnosis, HbA_1c, fasting and 60-min glucose at oral glucose tolerance test, BMI, and diabetes family history were significant independent determinants of AIT. Notably, only 9% of the attributable risk for AIT can be explained by the clinical factors studied. A modeled risk-scoring system was therefore a poor predictor of AIT.

CONCLUSIONS

Baseline maternal characteristics including HbA_1c alone cannot predict the need for AIT in GDM. Lifestyle, compliance, or as yet unmeasured influences play a greater role in determining AIT.The treatment of gestational diabetes mellitus (GDM) is important to lower the risk of perinatal complications (1) and, to achieve this, a proportion of women require intensive antenatal insulin treatment (AIT). The rising incidence of GDM (2), coupled with the recent revision of GDM diagnostic criteria (3), is predicted to conservatively increase the incidence of GDM by ∼30%, with significant implications for the numbers requiring AIT and clinical workload (4). With this looming spectre, it has been suggested that improved efficiency of health care delivery in GDM relies on improved risk stratification that would allow for triage to low- or higher-risk clinics (4). Consequently, there is interest in the ability to predict GDM in early pregnancy (5), and because AIT is the most resource-intensive management component in GDM, a risk-prediction tool that identifies patients likely to need AIT would have theoretical utility. Thus, the aim of this large cohort study was to determine if, using commonly available maternal clinical and biochemical characteristics at the time of GDM diagnosis, it was possible to develop an effective and easily implemented AIT prediction tool.     

The relationship among pain, sensory loss, and small nerve fibers in diabetes

OBJECTIVE: Many individuals with diabetes experience neuropathic pain, often without objective signs of large-fiber neuropathy. We examined intraepidermal nerve fibers (IENFs) to evaluate the role of small nerve fibers in the genesis of neuropathic pain. RESEARCH DESIGN AND METHODS: Twenty-five diabetic subjects with neuropathic pain and 13 without were studied. The pain was present for at least 6 months for which no other cause could be found. Punch skin biopsies were obtained from the distal leg. IENFs were stained using antibody to protein gene product 9.5 and counted with confocal microscopy. Neuropathy was graded by vibration perception and cold detection thresholds and the Michigan Neuropathy Screening Instrument. RESULTS: In the total cohort, IENF density was significantly lower in those with pain compared with those without (3 [1-6] vs. 10 [3-19], respectively, P = 0.02). There were significant inverse correlations between IENF and severity of neuropathy, with the pain group having a flatter gradient than their pain-free counterparts (P < 0.02). The difference in IENF density was greatest in subjects with less objective evidence of neuropathy (P < or = 0.01). CONCLUSIONS: More severe loss of IENF is associated with the presence of neuropathic pain only in those with little or no objective sign of neuropathy. Thus, loss of IENF cannot explain pain in all cases, suggesting that different mechanisms underpin the genesis of pain at various stages of neuropathy.     

Why Does Ethnicity Affect Prevalence of Gestational Diabetes? The Underwater Volcano Theory

To study why gestational diabetes (GDM) is more common in some ethnic groups than others, we tested the hypothesis that GDM is more common in people who are temporally closer to developing non-insulin-dependent (Type 2) diabetes mellitus (NIDDM). The prevalence of GDM and the mean age of affected women in each major ethnic group were determined. From our database of NIDDM 6052 patients, the mean age of onset in each ethnic group was calculated and the mean difference between age of developing GDM and age of developing NIDDM derived (NIDDM–GDM age gap). This age gap was used to adjust for the susceptibility to GDM of each group. The overall prevalence of GDM was 6.7 % (CI 6.0 %–7.4 %). In Anglo-Celtic women it was 3.0 % (CI 2.3 %–3.7 %). For the other ethnic groups the prevalence and odds ratio (OR) were: Chinese (15.0 % CI 11.8 %–18.2 % OR 5.6), Vietnamese (9.6 % CI 6.6 %–12.5 % OR 3.6), Indian (16.7 % CI 9.8 %–23.5 % OR 6.4), Arabic (7.3 % CI 4.6 %–10.1 % OR 2.5) and Aborigines (10.1 % CI 3.8 %–16.4 % OR 3.7). The OR for susceptibility to GDM did not change after adjustment for BMI and maternal age and it correlated significantly with the NIDDM–GDM age gap (r = −0.85; p = 0.03). However, it fell substantially after adjustment for NIDDM-GDM age gap. For women of different ethnic origins there is a difference in the time gap between their pregnancies and the time at which they would on average be expected to develop diabetes. This difference may be an important factor underlying the higher prevalence of GDM in some ethnic populations.