A comparative study of the different diagnostic criteria of gestational diabetes mellitus and its incidence

Background

High prevalence of diabetes and genetic predisposition to metabolic syndrome among Indians places Indian women at risk to develop gestational diabetes mellitus (GDM) and its complications. Literature defines multiple criteria for GDM. This prospective study compares available diagnostic criteria for GDM in Indian women and their correlation with perinatal morbidity.

Method

Nine hundred and forty-eight consecutive voluntary nondiabetic pregnant women were recruited for the study. Seven hundred and twenty-three of these (mean age 23.45 years; 75.7% < 25 years) who reported for the follow-up were screened for GDM at 24–28 weeks gestation by American College of Obstetrics and Gynaecology (ACOG) guidelines and World Health Organization (WHO) criteria. Glycated haemoglobin (HbA_1c) and fasting and two-hours postglucose plasma insulin levels were also analysed. Pregnancy outcome was known for 291 of these. Concordance of risk factors and perinatal complications was analysed with respect to GDM.

Results

Prevalence of GDM at 24–28 weeks gestation was found to be 4.8% by WHO criteria, 6.36% by Carpenter and Coustan''s criteria, and 3.5% by O''Sullivan''s criteria. Prevalence was marginally higher in women of higher age, having past history of abortion or family history of diabetes mellitus (DM) (P > 0.05). None of these women had HbA_1c > 6%. Relative risk of abnormal delivery (pregnancy outcome) was 1.93, 1.39, and 1.17 in women with GDM by O''Sullivan''s, WHO, and Carpenter''s criteria, respectively (P > 0.05). Abnormal deliveries were marginally higher in women with high postglucose load insulin levels. Mean weight of the newborns was essentially the same in GDM and nonGDM women by any of the criteria. One-hour and two-hours postglucose values were more sensitive in diagnosing GDM by O''Sullivan''s criteria while fasting plasma glucose value had the poorest specificity with 2.5% of nonGDM women having values above the cut-off. Modifications of these criteria did not im-prove their predictive value for abnormal delivery over that of O''Sullivan''s criteria.

Conclusion

Prevalence of GDM and abnormal delivery in women < 35 years of age is low. Therefore, global screening for GDM may not be very useful in women < 25 years of age unless family history of DM or past history of abortion is present. Existing evidence is inadequate to justify the switchover from O''Sullivan''s criteria for diagnosis of GDM.Key Words: Carpenter''s criteria, GDM, O''Sullivan''s criteria, WHO criteria     

A comparative study of the different diagnostic criteria of gestational diabetes mellitus and its incidence

Background

High prevalence of diabetes and genetic predisposition to metabolic syndrome among Indians places Indian women at risk to develop gestational diabetes mellitus (GDM) and its complications. Literature defines multiple criteria for GDM. This prospective study compares available diagnostic criteria for GDM in Indian women and their correlation with perinatal morbidity.

Method

Nine hundred and forty-eight consecutive voluntary nondiabetic pregnant women were recruited for the study. Seven hundred and twenty-three of these (mean age 23.45 years; 75.7% < 25 years) who reported for the follow-up were screened for GDM at 24–28 weeks gestation by American College of Obstetrics and Gynaecology (ACOG) guidelines and World Health Organization (WHO) criteria. Glycated haemoglobin (HbA_1c) and fasting and two-hours postglucose plasma insulin levels were also analysed. Pregnancy outcome was known for 291 of these. Concordance of risk factors and perinatal complications was analysed with respect to GDM.

Results

Prevalence of GDM at 24–28 weeks gestation was found to be 4.8% by WHO criteria, 6.36% by Carpenter and Coustan's criteria, and 3.5% by O'Sullivan's criteria. Prevalence was marginally higher in women of higher age, having past history of abortion or family history of diabetes mellitus (DM) (P > 0.05). None of these women had HbA_1c > 6%. Relative risk of abnormal delivery (pregnancy outcome) was 1.93, 1.39, and 1.17 in women with GDM by O'Sullivan's, WHO, and Carpenter's criteria, respectively (P > 0.05). Abnormal deliveries were marginally higher in women with high postglucose load insulin levels. Mean weight of the newborns was essentially the same in GDM and nonGDM women by any of the criteria. One-hour and two-hours postglucose values were more sensitive in diagnosing GDM by O'Sullivan's criteria while fasting plasma glucose value had the poorest specificity with 2.5% of nonGDM women having values above the cut-off. Modifications of these criteria did not im-prove their predictive value for abnormal delivery over that of O'Sullivan's criteria.

Conclusion

Prevalence of GDM and abnormal delivery in women < 35 years of age is low. Therefore, global screening for GDM may not be very useful in women < 25 years of age unless family history of DM or past history of abortion is present. Existing evidence is inadequate to justify the switchover from O'Sullivan's criteria for diagnosis of GDM.     

Epithelial regeneration from bioengineered skin explants in culture

BACKGROUND: Artificial skin substitutes are beneficial in the treatment of chronic wounds although their performance relative to authentic human skin is unclear. OBJECTIVES: We compared the rate of outgrowth and morphology of neoepidermis from a bioengineered skin construct (Apligraf) with normal adult human skin explants on de-epidermized human dermal growth substrate with or without intact epidermal basement membrane zone. METHODS: Epithelial outgrowth of air-exposed cultures in serum-supplemented keratinocyte medium was quantified by fluorescence imaging, morphology by light microscopy, biomarkers of keratinocyte activation, proliferation and migration by immunohistochemical analysis, and gelatinases by zymography. RESULTS: Resurfacing from bioengineereed skin explants started earlier than from normal skin but subsequently, from day 3 to day 9, the rate of epidermalization from bioengineered skin was only 40% (206 +/- 23 microm day(-1), mean +/- SEM) of that of authentic skin (521 +/- 17 microm day(-1), P < 0.001). At culture termination at day 11, normal human skin had formed a multilayered and well-structured neoepidermis covering 41.0 +/- 1.2 mm2 of the dermal substrate while bioengineered skin produced a thinner, less organized epithelium covering 20.4 +/- 3.0 mm2. At this later stage, a higher expression of beta-defensin-2, keratin 16, Ki67 and matrix metalloproteinase (MMP)-9 was found in neoepidermis formed from authentic skin than from bioengineered skin. Activated MMP-2 was elevated in bioengineered skin-derived neoepidermis. Minor epithelial outgrowth was noted with either skin type on the dermal substrate devoid of basement membrane zone. CONCLUSIONS: Cultured normal skin explants produced a more uniform and expansive in vivo-like neoepidermis than bioengineered skin explants.     

Comparison of growth-inhibitory agents by fluorescence imaging of human skin re-epithelialization in vitro

Drug screening procedures should preferably utilize experimental settings mimicking the in vivo situation. The aim of this study was to evaluate a skin explant model as a tool to identify topical agents with anti-proliferative properties in human epidermis. Re-epithelialization was initiated from a skin punch biopsy explanted onto de-epidermized dermis and cultured at the air-liquid interface in the presence of epidermal growth factor receptor inhibitor PKI166, tacrolimus or established topical anti-psoriatic drugs: betamethasone, calcipotriol, dithranol and tazarotene. Neo-epidermal extension was traced by fluorescence microscopy prior to histomorphometric analysis. PKI166 at 1 microM decreased the mean radial outgrowth rate (-19%), frequency of BrdU-positive (-37%) and laminin 5-positive (-45%) cells, indicating reduced proliferation and migration of neo-epidermal keratinocytes. However, the papillomatosis index and epithelial thickness were not significantly affected. Calcipotriol at 1 microM had a similar effect on the outgrowth rate (-15%) and fraction of laminin 5-stained keratinocytes (-40%). Furthermore, calcipotriol significantly reduced mean neo-epidermal thickness. Equimolar concentrations of the other test compounds had no apparent effect on histology or outgrowth parameters. This study exemplifies the versatility of combined dynamic and morphological analysis and emphasizes the potential of epidermal growth factor receptor-directed inhibition in hyperproliferative disorders of the epidermis.     

High frequency oscillation and exogenous surfactant in the treatment of neonatal respiratory distress syndrome

Surfactant therapy has become widely used in neonates suffering from respiratory distress syndrome. High frequency oscillation has been shown to be efficient and safe in animal models, but somewhat less convincing in human neonates. An overview is given of the experimental and clinical data assessing the combination of these two techniques. Personal preliminary data are briefly presented.