Gestational diabetes mellitus--implications of different treatment protocols

OBJECTIVE: To assess the impact of different management approaches to gestational diabetes mellitus (GDM) on perinatal outcome. PATIENTS AND METHODS: The study group consisted of 2,060 patients with GDM treated in our center from January 1980 through December 1999. Four time periods were defined on the basis of changes in treatment protocols. Perinatal complications were compared between the periods and with normal pregnancy controls. RESULTS: The last two periods (1993-1999) were characterized by lower mean glucose level, lower mean gestational age at delivery, and a decline in macrosomia, shoulder dystocia and perinatal mortality rates, but also by high rates of labor induction and Cesarean delivery. A significant difference was found between the GDM and normal control groups in rates of labor induction (38.6% vs 10.8%, p < 0.001) and Cesarean delivery (34% vs 20%, p < 0.001) for the last period. CONCLUSIONS: Perinatal complications are preventable with good glycemic control and early induction of labor, but at a cost of a higher Cesarean section rate.     

The postprandial glucose profile in the diabetic pregnancy

OBJECTIVE: A controversy exists regarding the time to monitor blood glucose in the diabetic pregnancy (60 or 120 minutes after meals). Using a novel approach that provides continuous measurement of blood glucose, we sought to determine postprandial glucose profile in the diabetic pregnancy. STUDY DESIGN: Subjects were connected to a continuous glucose monitoring system for 72 consecutive hours. A continuous glucose monitoring system measures the interstitial glucose levels in subcutaneous tissue every 5 minutes. Women were instructed to record the time of each meal during the study period. For each meal, the first 240 minutes were analyzed. RESULTS: Sixty-five women participated in the study: 26 women were treated by diet alone; 19 women received insulin therapy, and 20 women had type 1 diabetes mellitus. The time interval from meal to peak postprandial glucose levels was similar in all the evaluated types of diabetic pregnancies and in good and poor control insulin-treated patients with gestational diabetes mellitus (approximately 90 minutes). Failure to return to preprandial glucose values within a 3-hour observation period was identified in approximately 50% of the patients. A similar postprandial glucose peak time was obtained for breakfast, lunch, and dinner in all study groups. Postprandial hypoglycemia events were noted in approximately 10% of the meals and occurred about 160 minutes after mealtime. CONCLUSION: The time interval for postprandial glucose peak in diabetic pregnancies is approximately 90 minutes after meals throughout the day and is not affected by the level of glycemic control. This information should be considered in the treatment of diabetes mellitus in pregnancy.     

Undiagnosed asymptomatic hypoglycemia: diet, insulin, and glyburide for gestational diabetic pregnancy

OBJECTIVE: The role of maternal hypoglycemia during pregnancy has not yet been established. We sought to estimate the prevalence of undiagnosed, asymptomatic hypoglycemic events that occur in diabetic patients. METHODS: All patients were evaluated using a continuous glucose monitoring system for 72 consecutive hours. The continuous glucose monitoring system measures in subcutaneous tissue interstitial glucose levels within a range of 40-400 mg/dL every 5 minutes for a total of 288 measurements per day. All patients were instructed regarding diabetic diet and assigned to pharmacological treatment as needed. Patients documented the time of food intake, insulin or glyburide administration, and all clinical hypoglycemic events. An asymptomatic hypoglycemic episode was defined as more than 30 consecutive minutes of glucose value below 50 mg/dL detected only by continuous glucose monitoring system reading without patient awareness. RESULTS: An evaluation of 82 patients with gestational diabetes was performed; 30 were insulin-treated, 27 were managed by diet only, and 25 were patients treated with glyburide. For purposes of comparison, data were obtained from 35 nondiabetic gravid women. Asymptomatic hypoglycemic events were identified in 19 of 30 (63%) insulin-treated patients and in 7 of 25 (28%) glyburide-treated patients. No hypoglycemic events were identified in patients with gestational diabetes mellitus treated by diet alone or in nondiabetic subjects. The mean recorded hypoglycemic episodes per day was significantly higher in insulin-treated patients (4.2 +/- 2.1) than in glyburide-treated patients (2.1 +/- 1.1), P =.03. In insulin-treated patients, the majority of the hypoglycemic events were nocturnal (84%), whereas in glyburide-treated patients, episodes were identified equally by day and night. CONCLUSION: Our data suggest that asymptomatic hypoglycemic events are common during pharmacological treatment in gestational diabetic pregnancies. We speculate that this finding may be explained by treatment modality rather than by the disease itself.     

Neurobiologic changes in the hypothalamus associated with weight loss after gastric bypass

BACKGROUND: Effects of Roux-en-Y gastric bypass (RYGB) on hypothalamic food intake regulation have not been investigated. The hypothalamic arcuate nucleus (ARC) and the magnocellular (m) and parvocellular (p) parts of the paraventricular nucleus (PVN) regulate hunger and satiety, and are under control of the orexigenic neuropeptide Y (NPY), and the anorexigenic alpha-melanocyte stimulating hormone (alpha-MSH) and serotonin (5-HT). We hypothesized that after RYGB, weight loss is associated with hypothalamic down regulation of NPY and up regulation of 5-HT and alpha-MSH. STUDY DESIGN: Obesity was induced in 12 Sprague Dawley rats using a high-energy diet for 7 weeks, and then the rats were divided into three groups (n = 4/group): RYGB, sham-operated pair-fed (PF), and sham-operated ad libitum (obese control). Ten days after operation, immunohistochemical quantification of NPY, alpha-MSH, and 5-HT(1B)-receptors in ARC and PVN was performed. Data were analyzed using ANOVA and Tukey's test. RESULTS: Body weight decreased in RYGB (417 +/- 21 g; mean +/- SE) and in PF (436 +/- 14 g) rats 10 days after operation compared with obese control rats (484 +/- 15 g; p < 0.05 for each comparison). NPY in ARC, pPVN, and mPVN decreased by 43%, 43%, and 61%, respectively in RYGB and by 55%, 42%, and 71% in PF, respectively, compared with obese controls (p < 0.05 for each pairwise comparison). RYGB versus PF did not show differences. alpha-MSH in ARC, pPVN and mPVN increased by 35%, 175%, and 67%, respectively in RYGB and by 29%, 162%, and 116% in PF, respectively, compared with obese controls (each p < 0.05). In mPVN, alpha-MSH significantly decreased by 23% in RYGB versus PF (p < 0.05). 5-HT-(1B)-receptor in pPVN increased by 58% in RYGB and by 26% in PF, compared with obese controls (p < 0.05). Compared with obese controls, 5HT-(1B)-receptor in mPVN increased by 39% in RYGB (p < 0.05) and by 9% in PF (p > 0.05). An increase of 5-HT-(1B)-receptor in pPVN and mPVN occurred in RYGB versus PF (p < 0.05). CONCLUSIONS: Obese rats that undergo weight loss after RYGB demonstrate changes in hypothalamic down regulation of NPY and up regulation of alpha-MSH and serotonin.     

Invasive fungal rhinosinusitis in immunocompromised patients

INTRODUCTION: Invasive fungal rhinosinusitis (IFR) is one of the most important causes of morbidity and mortality in immunocompromised patients, principally those with cellular immunodeficiency, with mortality ranging from 50 to 80%. Prophylaxis and early diagnosis increase the chances of successful treatment. STUDY DESIGN: Clinical prospective randomized study. AIM: To present cases of IFR and to compare them with data reported in the literature. MATERIAL AND METHODS: Analysis of eleven cases of IFR confirmed by pathologist examination. RESULTS: Aspergillus was found to be the most prevalent pathogen. Symptoms ranged from high fever in most cases to nasal discharge, ulceration of the nasal mucosa, headache and periorbital edema. CONCLUSION: The combination of amphotericin B and endoscopic surgery, associated or not with Caldwell-Luc surgery, showed good results. The use of liposomal amphotericin B also presented a satisfactory outcome.     

Do women prefer to have screening tests for Down syndrome that have the lowest screen-positive rate or the highest detection rate?

OBJECTIVE: To assess whether women have a preference for Down syndrome screening test performance. METHODS: A structured questionnaire exploring women's preferences for screening test performance was administered to women attending their first prenatal visit who wished to have Down syndrome screening performed. RESULTS: One hundred and twenty women were interviewed. The majority of women (n=80) chose a screening test with a low screen-positive rate rather than the highest detection rate. The reasons given for this preference were a desire to minimise the risk of miscarriage of a normal baby and a belief that a detection rate of 80 to 90% was acceptable. However, older women (>37 years) chose a test with the highest detection rate possible, regardless of the higher screen-positive rate, preferring to miscarry a normal baby as a result of a diagnostic test rather than miss the detection of a baby with Down syndrome. Preferences were not influenced by previous screening experience. CONCLUSIONS: Women express different preferences for screening test performance. Maternal age rather than previous screening experiences appears to be the major influence in these choices.