The effect of pre-pregnancy counselling for women with pre-gestational diabetes on maternal health status.

OBJECTIVE: To assess the impact of pre-pregnancy counselling (PPC) on the health of diabetic women in early pregnancy as compared to their health at the time of PPC. STUDY DESIGN: Retrospective cohort study involving all the diabetic women who attended PPC and subsequently become pregnant in the decade 1997-2007. The proforma had two sections: one for the PPC visit and one for the booking visit. Details on demographic factors, control and complications of diabetes, folic acid, current medication, weight, contraception, smoking and alcohol consumption were documented. RESULTS: Fifty-seven women who became pregnant after PPC were studied. There was optimisation of diabetic control with a significant reduction in HbA1c levels at booking as compared to PPC (7.5% vs 8.8%, p<0.0001). Diabetic surveillance (retinopathy and nephropathy screening) was up to date at the time of booking in >80% of the cases. Alteration of insulin regimes was undertaken in ∼ 1 in 5 women. Folic acid was taken by most patients (48/54) at booking. There was no significant reduction in the number of women who smoked at booking compared to PPC. CONCLUSION: The effect of PPC was evident in the improvements in the markers of health of diabetic women in early pregnancy compared to at the time of PPC.

Sulphonyurea as a cause of severe hypoglycaemia in the community.

INTRODUCTION: Hypoglycaemia is a well recognised side effect of insulin and sulphonyurea therapy in the treatment of, patients with diabetes mellitus. METHODS: We performed a retrospective analysis of patients who developed severe hypoglycaemia in Hull and, East Yorkshire, United Kingdom over a 4-month period to assess the different therapies that contribute the most to the problem and the patient groups who are at greatest risk. RESULTS: Of the 75 patients with diabetes mellitus who developed severe hypoglycaemia, 61 (80%) were taking, insulin, 5 in combination with metformin. Ten (13%) patients were taking SU therapy; 5 in, combination with metformin, 2 in combination with a thiazolidinedione and 1 in combination with, insulin. When the SU-treated and non-SU treated groups were compared, patients taking SU therapy were, significantly older and had significantly lower HbA1c levels. CONCLUSIONS: All patients taking SU and insulin treatment are potentially at risk of developing hypoglycaemia. Our, analysis shows that almost 15% of patients in our region who suffered from severe hypoglycaemia, were on SU therapy. Patients in this group were older and had lower levels of HbA1c. Whilst national HbA1c targets may be useful for clinicians to define glycaemic targets for their, population, this has to be tempered by what is in the best interests of the patient and not what is, dictated by the Quality and Outcomes Framework. Possible alternatives to SU therapy should be, considered especially if hypoglycaemia is a concern.

The potential for the use of insulin lispro in pregnancy complicated by diabetes.

The target of improved perinatal outcome in diabetic pregnancies may be achieved by new insulin preparations that more closely mirror the physiological response of insulin and not exclusively the traditional means of strict adherence to diet and frequent blood glucose testing.No insulin preparation has been systematically tested in pregnancy; it is a responsibility of all clinicians who look after pregnant diabetic women to record the outcomes of IL-treated pregnancies. More data is needed before this preparation can be either recommended in pregnancy or alternatively avoided.

Neuroendocrinology of female aging.

BACKGROUND: Because the average human life span has increased, a greater part of more women's lives will be lived in a hypoestrogenic state. OBJECTIVE: This article provides an overview of our current knowledge of the neuroendocrine processes in the aging female brain. METHODS: Using the search terms cardiovascular disease, cognition, dementia, depression, estrogens, female aging, gonadotropins, immune function, mood, neuroendocrinology, neurotransmitters, osteoporosis, and ovarian steroids, a review of English-language literature on the MEDLINE database was conducted from 1970 through June 2004. RESULTS: It is thought that the temporal patterns of neural signals are altered during middle age, leading to cessation of reproductive cycles, and that the complex interplay of ovarian and hypothalamic/pituitary pacemakers becomes increasingly dysfunctional with aging, ultimately resulting in menopause. Estrogen deficiency is associated with low mood, whereas estrogen therapy tends to be linked with improvements in measures of well-being and a decline in depression scores. It is likely that these effects of estrogens are mediated through changes in the metabolism of serotonin and nor epinephrine. Evidence exists to support the role of estrogens in specific effects on cognitive functioning in women, enhancing aspects of verbal memory, abstract reasoning, and information processing. Significant gender dimorphism is evident in both humoral and cell-mediated immune responses. The effects of estrogens on the cardiovascular system are complex; recent evidence suggests a negative role for oral estrogen in primary and secondary prevention of cardiovascular events. Additionally, estrogens increase the risk of stroke, and estrogen deficiency influences the pathogenesis of osteoporosis in both men and women. CONCLUSIONS: Changes in the neuroendocrine system due to the loss of ovarian function at menopause have an important biological role in the control of reproductive and nonreproductive functions, and regulate mood, memory, cognition, behavior, immune function, the locomotor system, and cardiovascular functions. More detailed insights are needed into the complex mechanisms of neuroendocrine alterations with aging.

Smell perception during early pregnancy: no evidence of an adaptive mechanism.

OBJECTIVE: It has been suggested that nausea and vomiting in pregnancy is an evolutionary adaptive mechanism to avoid the ingestion of potentially harmful foods. It has also been suggested that the mechanism that triggers nausea and vomiting in pregnancy may be olfaction and that olfactory senses are invoked to provide this protection. This study aimed to test this theory in a systematic design. DESIGN: Cross sectional study. SETTING: The antenatal department of a maternity hospital in the north of England. SAMPLE: Three groups of participants: pregnant women (n= 55), non-pregnant women (n= 42) and men (n= 48). METHODS: Sensitivity was tested towards the odours of six standard stimuli (half safe and half associated with potentially harmful compounds). MAIN OUTCOME MEASURES: Odour rating of likeness, strength and pleasantness. RESULTS: Pregnant women rated safe and odours with potentially harmful compounds differently but not more so than men or non-pregnant women. There was no evidence that pregnancy changed the olfactory processes from the non-pregnant state and only slight differences between pregnant women and men were recorded. CONCLUSIONS: There was no evidence that olfactory processes had undergone any adaptation during pregnancy. The ability to differentiate safe from potentially harmful compounds was common to all three groups studied.

Dermatological care of the diabetic foot.

Approximately 30% of patients with diabetes mellitus will have disease-related dermatological problems. Dry skin can be associated with autonomic neuropathy and may be fragile, promoting bacterial invasion. Any potentially infected 'diabetic foot' must be taken seriously, and non-painful deep sepsis suspected if there is evidence of sensory loss. Consideration should be given to eliminating nasal carriage of staphylococci if recurrent superficial sepsis occurs in the presence of poor diabetic control. Fungal infections, both of skin and nails, are common but usually not serious in the absence of immunosuppression. Treatment with topical antifungals may need to be combined with systemic therapy for successful eradication. Systemic antifungal therapy should be carefully considered as treatment needs to be prolonged and is potentially toxic, particularly in individuals with diabetes mellitus who often have co-morbidities. Varicose eczema should be treated by physical therapies intended to improve venous return and prevent peripheral edema and tissue injury. Allergic dermatitis is commonly associated with topical treatments and other sensitizers. Many reactions are not apparent from history, and patch testing for sensitivity is recommended. There are several diabetes mellitus-specific conditions that dermatologists must be aware of, including, necrobiosis lipoidica diabeticorum, granuloma annulare, diabetic dermopathy (spotted leg syndrome or shin spots), diabetic bullae (bullosis diabeticorum), and limited joint mobility and waxy skin syndrome. Ulceration, due to varying combinations of peripheral vascular disease and sensory neuropathy, is the province of the specialist team dealing with the diabetic foot and should ideally be referred to an appropriate multidisciplinary team.

A novel approach to the diagnosis and assessment of symptomatic diabetic neuropathy.

The McGill Pain Questionnaire has previously been shown to be useful in the differential diagnosis of painful conditions and has also been used to assess the efficacy of therapeutic intervention. We have applied this simple test to 42 patients with painful diabetic neuropathy and 49 control subjects with painful legs or feet of varying aetiologies. Analysis of responses by stepwise linear discriminant analysis confirmed a significant difference between the 2 groups (Wilks' lambda, P less than 0.001). Each questionnaire was given a single score as a result of the analysis, and this score correctly classified a total of 91% to either the neuropathic or control groups, and when applied prospectively to a further 25 ungrouped questionnaires a useful probability of their belonging to a diagnostic group was obtained. Use of the questionnaire might be a useful aid to the differential diagnosis of the painful diabetic leg.