Gestational diabetes: is a higher cesarean section rate inevitable?

OBJECTIVE: To determine the rate of and indication for cesarean section for women with gestational diabetes mellitus (GDM) compared with glucose-tolerant women. RESEARCH DESIGN AND METHODS: From a consecutive series of women with GDM seen over a 9-year period for medical management, women who had had a cesarean section were identified and the reason for the section determined from a review of the medical record. A control group of women who had had a section were obtained from an existing database of glucose-tolerant women. RESULTS: The section rate for women with GDM was higher at 19.8% than the 15.6% for glucose-tolerant women. However, after adjustment for age and parity, no significant differences were found. There were also no differences found for the primary indication for section. CONCLUSIONS: In our health area of New South Wales, Australia, women with GDM do not have a higher section rate compared with glucose-tolerant women. Concerns about the diagnosis of GDM leading to an increased rate of obstetric intervention should not be generalized.

Birth weight of women with gestational diabetes.

OBJECTIVE: Epidemiological observations have suggested a relationship between type 2 diabetes and a low birth weight. However, there are many confounding variables and problems with retrospective data collection. Women with gestational diabetes mellitus (GDM), who are likely to develop type 2 diabetes in the future, may help clarify these observations. RESEARCH DESIGN AND METHODS: Consecutive women with GDM (n = 138) were included in the study if they had a singleton pregnancy delivered between 37 and 41 weeks of gestation, if they had themselves been born in the local hospital, and if their own delivery data were available. With respect to their own births, a matched group was obtained by considering the next female delivery of the same gestational age. RESULTS: For women with GDM, the mean (+/- 1 SD) birth weight was 3,293 +/- 493 g and the ponderal index was 27.0 +/- 2.4. Their values were not significantly different from the matched group, which had a birth weight of 3,315 +/- 460 g and a ponderal index of 27.0 +/- 2.5. After adjusting for the gestational age of delivery, the birth weight of women with GDM did not show a U-shaped distribution. CONCLUSIONS: After adjustment for the gestational age of delivery, women with GDM do not themselves have either a lower or higher birth weight than a matched group. These data suggest that women with GDM are either not a good surrogate for investigating the relationship between birth weight and type 2 diabetes or that correction for the gestational age of delivery removes the most important confounding variable. It is also possible that modern dietary changes may have altered the relationship.

Measurement of the delivery of dialysis in acute renal failure.

BACKGROUND: Recent studies in patients with acute renal failure (ARF) have shown a relationship between the delivered dose of dialysis and patient survival. However, there is currently no consensus on the appropriate method to measure the dose of dialysis in ARF patients. In this study, the dose of dialysis was measured by blood- and dialysate-based kinetic methods in a group of ARF patients who required intermittent hemodialysis. METHODS: Treatments were performed using a Fresenius 2008E volumetric hemodialysis machine with the ability to fractionally collect the spent dialysate. Single-, double-pool, and equilibrated Kt/V were determined from the pre-, immediate post-, and 30-minute post-blood urea nitrogen (BUN) measurements. The solute reduction index was determined from the collected dialysate, as well as the single- and double-pool Kt/V. RESULTS: Forty-six treatments in 28 consecutive patients were analyzed. The mean prescribed Kt/V (1.11 +/- 0.32) was significantly greater than the delivered dose estimated by single-pool (0.96 +/- 0.33), equilibrated (0.84 +/- 0.28), and double-pool (0.84 +/- 0.30) Kt/V (compared with prescribed, each P < 0.001). There was no statistical difference between the equilibrated and double-pool Kt/V (P = NS). The solute removal index, as determined from the dialysate, corresponded to a Kt/V of 0.56 +/- 0.27 and was significantly lower than the single-pool and double-pool Kt/V (each P < 0.001). CONCLUSION: Blood-based kinetics used to estimate the dose of dialysis in ARF patients on intermittent hemodialysis provide internally consistent results. However, when compared with dialysate-side kinetics, blood-based kinetics substantially overestimated the amount of solute (urea) removal.

Gestational diabetes mellitus. At what time should the postprandial glucose level be monitored?

OBJECTIVE: To compare selected pregnancy outcomes for women with gestational diabetes mellitus (GDM) with management based on testing either 1 hour or 2 hours postprandially according to the ADIPS recommendations. METHODS: Prospective study of consecutive women referred for the medical management of their GDM. Women were allowed to select whether they would test either 1 hour postprandial with a target glucose of < 8.0 mmol/L or 2 hours postprandial with a target glucose of <7.0 mmol/L. Changes to diet and the introduction and adjustment of insulin therapy were designed to maintain postprandial glucose levels below these targets. RESULTS: 166 women elected to test 1 hour postprandial and 101 elected to test 2 hours postprandial. There were no significant demographic differences between these 2 groups. The fetal birthweight, percentage of women requiring insulin and the total daily dose of insulin were similar in both groups. CONCLUSIONS: For women with GDM, monitoring either 1 hour or 2 hours postprandially led to similar outcomes. This would suggest that the ADIPS recommendations are equivalent and therefore women can choose the most convenient time for their postprandial monitoring.

Prescribed versus delivered dialysis in acute renal failure patients.

The current study was designed first to determine separately the prescribed and delivered dose of dialysis and, second, to determine what factors lead to failure to deliver the prescribed dose of dialysis in patients with acute renal failure (ARF). Forty patients, who collectively underwent 136 dialysis treatments, were studied prospectively at two institutions. The results showed that almost half the prescriptions (49%) were for a Kt/V less than 1.2 and, more importantly, nearly 70% of the treatments delivered a Kt/V less than 1.2, the minimally acceptable dose defined in the Dialysis Outcomes Quality Initiative (DOQI) guidelines for chronic hemodialysis (CHD) patients. Patient predialysis weight was the most important variable associated with a low prescribed and delivered dose of dialysis, as well as lack of delivery of the prescribed dose of dialysis. From the statistical model, it is estimated that for every 10-kg increase in predialysis weight, the chance of prescribing or delivering a Kt/V less than 1.2 increased 4.6- and 1.95-fold, respectively. The lower than prescribed blood flow achieved by the temporary catheters and patients not receiving anticoagulation were variables also associated with not receiving the prescribed Kt/V. It is concluded that patients with ARF are prescribed and receive a dose of dialysis that would be considered inadequate for CHD patients. Until the association between dose of dialysis and outcome is better defined, it would be prudent that both the dialysis prescription and the delivery of dialysis to patients with ARF should be performed with the same care and goals as that currently received by patients with end-stage renal disease (ESRD).

Minocycline-induced arthritis.

We describe seven women who developed acute polyarthritis after prolonged treatment with minocycline for acne. Arthritis persisted until minocycline was withdrawn, then recovered rapidly. A mild elevation of alanine or aspartate transaminase was noted in 4 patients, while pulmonary infiltrates were found in 2 patients. Antinuclear antibodies (ANA) were persistently present throughout treatment in 4 patients, but were only present on one occasion in 2 women and were absent in one. This syndrome has been described as "drug-induced lupus" although, as described with other drugs, many patients do not fulfil the diagnostic criteria for lupus. The proposed criteria for the diagnosis of "drug-induced lupus", which require only one clinical feature of SLE, also require a positive ANA test and therefore might exclude these patients. This could result in failure to recognise minocycline as the cause of the arthritis, and hence lead to prolonged illness and unnecessary investigations and treatment.

Predictive measures of vascular access thrombosis: a prospective study.

Malfunction of permanent vascular accesses remains a cause of frequent and costly morbidity in patients receiving chronic hemodialysis (CHD). Several recommendations for routine monitoring of these permanent vascular accesses for incipient failure have been proposed. In this study, multiple indicators of incipient vascular access dysfunction, including "venous" and "arterial" pressures at serial blood flows (200 ml/min, 300 ml/min, and 400 ml/min), percent urea recirculation, Doppler ultrasound, and access blood flow by ultrasound dilution technique were simultaneously evaluated in a total of 220 vascular accesses in 170 chronic hemodialysis patients in two separate study periods (6 months apart). The rate of thrombosis was determined within the subsequent 12 weeks of each study period to assess the short-term predictive power of access thrombosis. During the period of follow-up, there were 34 thrombotic events in 172 polytetrafluoroethylene (PTFE) grafts and only one thrombotic event in 48 arterio-venous fistulas (AVF). Therefore, the statistical analysis was limited to the PTFE grafts. When grafts with thromboses were compared to those without thrombosis by univariate analysis, access blood flow measured either by ultrasound dilution technique (875 +/- 426 ml/min with thrombosis vs. 1193 +/- 677 ml/min without thrombosis, P = 0.001) or by Doppler ultrasound (762 +/- 420 ml/min with thrombosis vs. 1171 +/- 657 ml/min without thrombosis, P = 0.001) were significantly different in the two groups. There was good correlation (r = 0.79, P = 0.0001) between the blood flows determined by both techniques. The grade of stenosis determined by ultrasound was also a statistically significant predictor (P = 0.02). "Venous" and "arterial" pressures were numerically similar and were not statistically different between the accesses that did and those that did not thrombose. When multivariate analysis was used, there was a significantly increased risk of thrombosis only with decreasing access blood flow determined by ultrasound dilution techniques after adjusting for other confounding variables. When the average blood flow of all grafts (1134 ml/min) is considered as the reference access blood flow (relative risk of 1.0), the relative risk of a PTFE thrombotic event within the subsequent 12 weeks was 1.23 at a blood flow 950 ml/min, 1.67 at a blood flow of 650 ml/min and to 2.39 at a blood flow of 300 ml/min. In summary, access blood flow measured by either Dilution or Doppler is a reliable indicator of subsequent short-term thrombosis risk. Other proposed methods of evaluating access dysfunction were not useful in our patients. If simple to use, cost-effective devices to measure dialysis access blood flow become readily available, the measurement of access blood flow will likely become the method of choice for screening of PTFE vascular access dysfunction in hemodialysis patients.

Chemical synthesis of dual-radiolabelled cyclandelate and its metabolism in rat hepatocytes and mouse J774 cells.

1. The chemical synthesis of 3,3,5-trimethyl[1-3H]cyclohexanol, 3,3,5-trimethyl[2,3-3H]cyclohexanol and 3,3,5-trimethyl[2,3-3H]cyclohexanyl[1-14C]mandelate (cyclandelate) are described. The ratio of 3H/14C radioactivity in the ester was 27:1. 2. Cultured rat hepatocytes accumulated trimethylcyclohexanol rapidly and excreted its glucuronide into the culture medium. Rat hepatocytes also accumulated cyclandelate rapidly, hydrolysing the ester and excreting trimethylcyclohexanol into the medium. This trimethylcyclohexanol then re-entered the cells and was converted to its glucuronide prior to excretion. 3. In contrast, no hydrolysis of cyclandelate was seen on incubation with J774 cells, a transformed mouse macrophage. 4. Similar differences in hydrolytic activity were seen with microsomal fractions prepared from rat liver and J774 cells. Hepatic microsomes caused a rapid hydrolysis of cyclandelate while no hydrolysis was detectable after incubations of over an hour with J774 microsomes. 5. This difference in hydrolytic activity may have important implications for the action of cyclandelate on cholesterol metabolism in extrahepatic tissues.

Variation in ten lysosomal hydrolase enzyme activities in inbred mouse strains.

Activities of 10 lysosomal hydrolase enzymes (beta-hexosaminidase, beta-galactosidase, alpha-galactosidase, alpha-mannosidase, beta-mannosidase, alpha-L-fucosidase, beta-glucuronidase, alpha-glucosidase, alpha-N-acetylgalactosaminidase, and acid phosphatase) were determined in eight organs (brain, liver, kidney, spleen, heart, skeletal muscle, lung, and testis) in males and females of six inbred mouse strains (C57BL/6J, C3H/HeJ, DBA/2J, BALB/cJ, P/J, and 129/J). Examples of enzyme-specific variation, organ-specific variation, and enzyme- and organ-specific variation were found. New enzyme-specific variants with the features of systemic regulators for alpha-L-fucosidase and beta-mannosidase were found. Known variants were detected. Organ-specific variants had some of the properties expected for a new class of genes affecting multiple enzymes: organ-specific regulators.

Estimates of heritabilities and of genetic and phenotypic correlations among growth and reproductive traits in yearling Angus bulls.

Data from Nichols Farm, Anita , Iowa, collected from 1975 through 1980, were used. Angus Herd Improvement Records with birth, weaning and yearling weights were obtained for 717 bulls by 80 sires. Also available, from Hawkeye Breeders Service, Des Moines , Iowa, were measures of sperm concentration and motility, percentage live sperm, number of sperm/ml, semen score and quality and scrotal circumference on the bulls as yearlings . Heritabilities and genetic and phenotypic correlations were estimated for the above traits from variance and covariance components calculated by restricted maximum likelihood. Estimates of heritability for birth, weaning and yearling weight were .70, .46 and .49, respectively. Heritability estimates for the semen traits were low (0 to .24); the estimate for scrotal circumference was .36. In general, genetic and phenotypic correlations among semen traits were high and favorable, with absolute values ranging between .49 and 1.11. Genetic correlations between semen traits and scrotal circumference were low; corresponding phenotypic correlations were moderate. Semen traits were lowly correlated phenotypically with growth traits (-.08 to .08) and genetic correlation estimates were variable. Estimates of phenotypic and genetic correlations suggested that yearling scrotal circumference was more closely related to yearling weight than to either birth or weaning weight. Estimates of phenotypic and genetic correlations between scrotal circumference and yearling weight were .26 and .68, respectively.

A controlled trial of health education in the physician's office.

Screening of 6,144 patients in a general practice clinic to assist physician case-finding uncovered 983 (16%) who were uncontrolled hypertensives. Following physician recommendation, 115 patients volunteered for a controlled trial to test the effectiveness of supplementary strategies to the pharmaceutical management of high blood pressure. A study of nonparticipants indicated that about 7% of the practice population was eligible for cardiovascular health education. One group received a health education program, a second was allocated to self-monitor their blood pressure for 6 months, a third group was allocated to both strategies, and the final group, acting as a control, continued to receive their usual care. Physician monitoring of patients continued for the duration of the study and blood pressures decreased in all patients. The study's most important outcome was the joint reduction of blood pressure and medication strength. These were assessed by a "blind" clinician before and after the interventions according to criteria set out in the "stepped-care" approach to management of high blood pressure. People allocated to a health education program conducted in the doctor's common room did twice as well on this measure as those who were not so educated. Daily self-monitoring of blood pressure for 6 months proved to be too much for the majority of those so instructed. It is concluded that the general practice setting remains an important place for health education to prevent cardiac disease and suggestions are made for incorporating this into everyday practice.

On a method of estimating the genetic correlation between characters measured in different experimental units.

Yamada's method of estimating genetic co-variances between traits measured in different experimental units is discussed. It is shown that if the data are unbalanced, this method gives biased estimates of genetic covariances unless the traits have identical genetic and residual variances. An alternative unbiased procedure is suggested.

Simple screening tests for the diagnosis of isolated clotting factor defects. With special reference to 'contact factor' defects.

Reagents may be prepared from normal plasma and used with the prothrombin time and partial thromboplastin time tests to distinguish isolated defects of factors I, II, VII, VIII, IX, X, XI, or XII.

Partial thromboplastin time test with kaolin: diagnosis of haemophilia and Christmas disease without natural reference plasmas.

Deficiencies of factor VIII (in haemophilia) and factor IX (in Christmas disease) prolong the partial thromboplastin time. If normal plasma is treated with alumina, the factor VIII remains but the factor IX is removed and can subsequently be recovered by elution of the alumina. If a long partial thromboplastin time is found on investigating a male patient whose history suggests a life-long bleeding disorder, the plasma may be retested after adding either alumina-adsorbed normal plasma or eluate. If the patient's partial thromboplastin time is shortened (relative to the control) by adding adsorbed normal plasma the patient is likely to be a haemophiliac; but if it is shortened by adding eluate then he is likely to have Christmas disease. Practical details for carrying out these manoeuvres are given and experiments on the validity of the test described.