Effect of a multidisciplinary team approach on the management of diabetic foot ulcers on the Central Coast: A review of the Gosford Hospital High-Risk Foot Clinic.

This retrospective cohort study aims to assess whether the implementation of a multidisciplinary approach in the Gosford Hospital High-Risk Foot Clinic improved outcomes of diabetic foot ulcers. Ulceration is a common foot complication of diabetes mellitus and greatly increases patient morbidity and mortality. Patients who attended at least one appointment at the Gosford Hospital High-Risk Foot Clinic in 2017 or 2019 were identified through the Gosford Hospital Podiatry department's records. The 2017 and 2019 cohorts were compared on measures of ulcer healing, incidence of amputation, incidence of vascular intervention and surgical debridement, percentage of patients admitted to hospital due to complications and use of systemic antibiotic therapy. Sixty-one patients in 2017 and 59 patients in 2019 met inclusion criteria, and from them, 207 ulcers were included. Between 2017 and 2019, there was a 6.2-week reduction in time to 100% ulcer healing in 2019 (p = 0.021), and 10.1% more ulcers healed within 52 weeks (p = 0.22, 95% confidence interval [CI] [-5.9%, 25.5%]). Whilst there was no significant difference in incidence of patients receiving amputation, there was an increased absolute number of amputations in 2019. Implementation of a multidisciplinary approach at the Gosford Hospital High-Risk Foot Clinic led to improvements in diabetic foot ulcer healing.

IDF Diabetes Atlas: Estimation of Global and Regional Gestational Diabetes Mellitus Prevalence for 2021 by International Association of Diabetes in Pregnancy Study Group's Criteria.

AIMS: The approaches used to screen and diagnose gestational diabetes mellitus (GDM) vary widely. We generated a comparable estimate of the global and regional prevalence of GDM by International Association of Diabetes in Pregnancy Study Group (IADPSG)'s criteria. METHODS: We searched PubMed and other databases and retrieved 57 studies to estimate the prevalence of GDM. Prevalence rate ratios of different diagnostic criteria, screening strategies and age groups, were used to standardize the prevalence of GDM in individual studies included in the analysis. Fixed effects meta-analysis was conducted to estimate standardized pooled prevalence of GDM by IDF regions and World Bank country income groups. RESULTS: The pooled global standardized prevalence of GDM was 14.0% (95% confidence interval: 13.97-14.04%). The regional standardized prevalence of GDM were 7.1% (7.0-7.2%) in North America and Caribbean (NAC), 7.8% (7.2-8.4%) in Europe (EUR), 10.4% (10.1-10.7%) in South America and Central America (SACA), 14.2% (14.0-14.4%) in Africa (AFR), 14.7% (14.7-14.8%) in Western Pacific (WP), 20.8% (20.2-21.4%) in South-East Asia (SEA) and 27.6% (26.9-28.4%) in Middle East and North Africa (MENA). The standardized prevalence of GDM in low-, middle- and high-income countries were 12.7% (11.0-14.6%), 9.2% (9.0-9.3%) and 14.2% (14.1-14.2%), respectively. CONCLUSIONS: The highest standardized prevalence of GDM was in MENA and SEA, followed by WP and AFR. Among the three World Bank country income groups, high income countries had the highest standardized prevalence of GDM. The standardized estimates for the prevalence of GDM provide an insight for the global picture of GDM.

IDF Diabetes Atlas: The prevalence of pre-existing diabetes in pregnancy - A systematic reviewand meta-analysis of studies published during 2010-2020.

OBJECTIVES: To estimate the prevalence of pre-existing diabetes in pregnancy from studies published during 2010-2020. METHODS: We searched PubMed, CINAHL, Scopus and other sources for relevant data sources. The prevalence of overall pre-existing, type 1 and type 2 diabetes, by country, region and period of study was synthesised from included studies using the inverse-variance heterogeneity model and the Freeman-Tukey transformation. Heterogeneity was assessed using the I2 statistic and publication bias using funnel plots. RESULTS: We identified 2479 records, of which 42 data sources with a total of 78 943 376 women, met the eligibility criteria. The included studies were from 17 countries in North America, Europe, the Middle East and North Africa, Australasia, Asia and Africa. The lowest prevalence was in Europe (0.5%, 95 %CI 0.4-0.7) and the highest in the Middle East and North Africa (2.4%, 95 %CI 1.5-3.1). The prevalence of pre-existing diabetes doubled from 0.5% (95 %CI 0.1-1.0) to 1.0% (95 %CI 0.6-1.5) during the period 1990-2020. The pooled prevalences of pre-existing type 1 and type 2 diabetes were 0.3% (95 %CI 0.2-0.4) and 0.2% (95 %CI 0.0-0.9) respectively. CONCLUSION: While the prevalence of pre-existing diabetes in pregnancy is low, it has doubled from 1990 to 2020.

The ADIPS Pilot National Diabetes in Pregnancy Benchmarking Programme.

BACKGROUND: To test the feasibility of benchmarking the care of women with pregnancies complicated by hyperglycaemia. METHODS: A retrospective audit of volunteer diabetes services in Australia and New Zealand involving singleton pregnancies resulting in live births between 2014 and 2020. Ranges are shown and compared across services. RESULTS: The audit included 10,144 pregnancies (gestational diabetes mellitus (GDM) = 8696; type 1 diabetes (T1D) = 435; type 2 diabetes (T2D) = 1013) from 11 diabetes services. Among women with GDM, diet alone was used in 39.4% (ranging among centres from 28.8-57.3%), metformin alone in 18.8% (0.4-43.7%), and metformin and insulin in 10.1% (1.5-23.4%); when compared between sites, all p < 0.001. Birth was by elective caesarean in 12.1% (3.6-23.7%) or emergency caesarean in 9.5% (3.5-21.2%) (all p < 0.001). Preterm births (<37 weeks) ranged from 3.7% to 9.4% (p < 0.05), large for gestational age 10.3-26.7% (p < 0.001), admission to special care nursery 16.7-25.0% (p < 0.001), and neonatal hypoglycaemia (<2.6 mmol/L) 6.0-27.0% (p < 0.001). Many women with T1D and T2D had limited pregnancy planning including first trimester hyperglycaemia (HbA1c > 6.5% (48 mmol/mol)), 78.4% and 54.6%, respectively (p < 0.001). CONCLUSION: Management of maternal hyperglycaemia and pregnancy outcomes varied significantly. The maintenance and extension of this benchmarking service provides opportunities to identify policy and clinical approaches to improve pregnancy outcomes among women with hyperglycaemia in pregnancy.

Comparison of Pregnancy Outcomes Using Different Gestational Diabetes Diagnostic Criteria and Treatment Thresholds in Multiethnic Communities between Two Tertiary Centres in Australian and New Zealand: Do They Make a Difference?

INTRODUCTION: Australia, but not New Zealand (NZ), has adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria to diagnose gestational diabetes (GDM). We compared pregnancy outcomes using these different diagnostic approaches. METHOD: Prospective data of women with GDM were collected from one NZ (NZ) and one Australian (Aus) hospital between 2007-2018. Aus screening criteria with 2-step risk-based 50 g Glucose Challenge Testing (GCT) followed by 75 g-oral glucose tolerance testing (OGTT): fasting ≥ 5.5, 2-h ≥ 8.0 mmol/L (ADIPS98) changed to a universal OGTT and fasting ≥5.1, 1-h ≥ 10, 2-h ≥ 8.5 mmol/L (IADPSG). NZ used GCT followed by OGTT with fasting ≥ 5.5, 2-h ≥ 9.0 mmol/L (NZSSD); in 2015 adopted a booking HbA1c (NZMOH). Primary outcome was a composite of macrosomia, perinatal death, preterm delivery, neonatal hypoglycaemia, and phototherapy. An Aus subset positive using NZSSD was also defined. RESULTS: The composite outcome odds ratio compared to IADPSG (1788 pregnancies) was higher for NZMOH (934 pregnancies) 2.227 (95%CI: 1.84-2.68), NZSSD (1344 pregnancies) 2.19 (1.83-2.61), and ADIPS98 (3452 pregnancies) 1.91 (1.66-2.20). Composite outcomes were similar between the Aus subset and NZ. CONCLUSIONS: The IADPSG diagnostic criteria were associated with the lowest rate of composite outcomes. Earlier NZ screening with HbA1c was not associated with a change in adverse pregnancy outcomes.

Projections of the prevalence of hyperglycaemia in pregnancy in 2019 and beyond: Results from the International Diabetes Federation Diabetes Atlas, 9th edition.

AIM: Hyperglycaemia in pregnancy (HIP) is one of the most common complications of pregnancy. This study aims to examine the projected HIP prevalence in 2030 and 2045 using multiple methods. METHODS: The International Diabetes Federation Diabetes Atlas 2019 prevalence was projected to 2030 and 2045 by: (1) carrying forward the 2019 age-adjusted prevalence rates; (2) applying a linear regression of the past four editions of the IDF Diabetes Atlas; (3) applying a regression of the previous editions with the most consistent trend, followed by extrapolation from the 9th edition HIP estimate. RESULTS: Respectively, for 2030 and 2045, Method 1 projected a declining HIP rate with prevalences of 14.0% and 13.3%, Method 2 projected an increasing HIP prevalence at 16.5% and 18.3%, Method 3 predicted stabilisation of the rate from 16.0% to 15.8%. CONCLUSION: Assuming other factors remain unchanged, our best estimation of age-adjusted HIP will show stabilisation between 2019 and 2045 of 15.8% to 16.0%. However, this estimate is confounded by the heterogeneity of studies and the influence of different gestational diabetes mellitus diagnostic criteria. To provide accurate future comparisons we recommend standardising the diagnostic criteria to the International Association of Diabetes in Pregnancy Study Groups.

Hypoglycaemia on an oral glucose tolerance test in pregnancy - Is it clinically significant?

AIM: During pregnancy, some women have a low glucose level on the 75 g oral glucose tolerance test (OGTT). The implications of this are unclear and there is no guideline on how to manage these women. METHOD: We recruited pregnant women with a glucose level <3.5 mmol/L at 1- or 2-h during a screening antenatal OGTT. These women (Group 1) underwent self-monitoring of blood glucose (SMBG) over a two-week period. We also compared Group 1's demographic and pregnancy outcomes data with women who had normal OGTT results (Group 2) and women diagnosed with gestational diabetes mellitus (GDM) (Group 3). RESULTS: 52 women were recruited. Post-hoc analysis of the SMBG results revealed 50% of women experienced 2 or more elevated fasting BGLs (>5.1 mmol/L) in a week when using the Australian Diabetes in Pregnancy Society (ADIPS) criteria. A further 8% women had elevated 2-h glucose levels (above 6.7 mmol/L). Group 1 women tended to have higher booking weight. They were less likely to have a history of macrosomia or be of East or South-East Asian ethnicity. There were no differences in pregnancy outcomes between Groups 1 and 2, but Group 1 had a higher rate of congenital abnormality (6%) than Group 3 (2%). CONCLUSION: A large proportion of pregnant women who had a low glucose level on OGTT had elevated glucose levels on SMBG, however their pregnancy outcomes were not significantly different to women who had a normal OGTT. Currently there is not enough evidence to advocate routine SMBG and treatment for this group of women.

Ethnic Disparities in Gestational Diabetes.

PURPOSE OF REVIEW: Ethnicity has long been described as a major risk factor for the development of gestational diabetes mellitus (GDM), and it is widely recognised that women from ethnicities other than Europids are at higher risk of developing GDM. There are also described differences between ethnicities in key GDM pregnancy outcomes. This review describes some of the factors that relate to the ethnic disparities in GDM. RECENT FINDINGS: The global prevalence of GDM has been steadily increasing and estimated to be 16.2% from the International Diabetes Federation extrapolation. Reported prevalence rates may understate the true prevalence, due to factors of access and attitudes to GDM diagnosis and screening in low resource settings for foreign-born women and indigenous populations. Other factors may relate to genes associated with specific ethnicities, obesity, body composition and gestational weight gain. Various factors such as access to screening, body composition, genetics and gestational weight gain may result in ethnic disparities in the prevalence and outcomes of GDM.

Gestational diabetes mellitus: Challenges for different ethnic groups.

Ethnicity is defined as "belonging to a social group that has a common national or cultural tradition". Membership of certain ethnic groups has long been associated with increased risk of gestational diabetes mellitus (GDM). Studies that examined ethnic differences amongst women with GDM were often conducted in western countries where women from various ethnic backgrounds were represented. The prevalence of GDM appears to be particularly high among women from South Asia and South East Asia, compared to Caucasian, African-American and Hispanic communities. For some, but not all ethnic groups, the body mass index is a risk factor for the development of GDM. Even within a particular ethnic group, those who were born in their native countries have a different risk profile for GDM compared to those born in western countries. In terms of treatment, medical nutrition therapy (MNT) plays a key role in the management of GDM and the prescription of MNT should be culturally sensitive. Limited studies have shown that women who live in an English-speaking country but predominantly speak a language other than English, have lower rates of dietary understanding compared with their English speaking counterparts, and this may affect compliance to therapy. Insulin therapy also plays an important role and there appears to be variation as to the progression of women who progress to requiring insulin among different ethnicities. As for peri-natal outcomes, women from Pacific Islander countries have higher rates of macrosomia, while women from Chinese backgrounds had lower adverse pregnancy outcomes. From a maternal outcome point of view, pregnant women from Asia with GDM have a higher incidence of abnormal glucose tolerance test results post-partum and hence a higher risk of future development of type 2 diabetes mellitus. On the other hand, women from Hispanic or African-American backgrounds with GDM are more likely to develop hypertension post-partum. This review highlights the fact that management needs to be individualised and the clinician should be mindful of the impact that differences in ethnicity may have on the clinical characteristics and pregnancy outcomes in women affected by GDM, particularly those living in Western countries. Understanding these differences is critical in the delivery of optimal antenatal care for women from diverse ethnic backgrounds.