Progression of diabetic retinopathy in women with pregestational diabetes during pregnancy and postpartum.

BACKGROUND: Diabetic retinopathy (DR) may worsen during pregnancy, but its course in the postpartum remains poorly understood. Understanding the natural history of DR during and after pregnancy can help determine when sight-threatening DR treatment should be administered. METHODS: A prospective longitudinal cohort study recruited pregnant women with pre-existing type 1 (T1D) or type 2 diabetes from two tertiary Diabetes Antenatal Clinics in Melbourne, Australia. Eye examination results in early pregnancy, late pregnancy, and up to 12-months postpartum were compared to determine DR changes. Two-field fundus photographs and optical coherence tomography scans were used to assess DR severity. RESULTS: Overall, 105 (61.4%) women had at least two eye examinations during the observation period. Mean age was 33.5 years (range 19-51); 54 women (51.4%) had T1D; 63% had HbA1c <7% in early pregnancy. DR progression rate was 23.8% (95% CI 16.4-32.6). Having T1D (RR 4.96, 95% CI 1.83-13.46), pre-existing DR in either eye (RR 4.54, 95% CI 2.39-8.61), and elevated systolic blood pressure (adjusted RR 2.49, 95% CI 1.10-5.66) were associated with increased risk of progression. Sight-threatening progression was observed in 9.5% of women. Among the 19 eyes with progression during pregnancy, 15 eyes remained stable, three eyes progressed, and only one eye regressed in the postpartum. CONCLUSIONS: Nearly 1 in 4 women had DR progression from conception through to 12-months postpartum; almost half of these developing sight-threatening disease. DR progression occurring during pregnancy was found to predominantly remain unchanged, or worsen, after delivery, with very few eyes spontaneously improving postpartum.

Prevalence of diabetic retinopathy in women with pregestational diabetes during pregnancy and the postpartum.

BACKGROUND: Diabetic retinopathy (DR) may be affected by pregnancy. The majority of prevalence data regarding DR in pregnancy predate the advent of contemporary guidelines for diabetes management during pregnancy. This study reports DR prevalence and associated risk factors in women with pregestational diabetes during pregnancy and the postpartum in Australia. METHODS: A total of 172 pregnant women with type 1 (T1DM) or type 2 diabetes diagnosed pre-pregnancy were prospectively recruited from two obstetrics hospitals in Melbourne (November 2017-March 2020). Eye examinations were scheduled in each trimester, at 3-, 6-, and 12-months postpartum. DR severity was graded from two-field fundus photographs by an independent grader utilising the Airlie House Classification. Sight-threatening DR (STDR) was defined as the presence of diabetic macular oedema or proliferative DR. RESULTS: Overall, 146 (84.9%) women had at least one eye examination during pregnancy. The mean age was 33.8 years (range 19-51), median diabetes duration was 7.0 years (IQR 3.0-17.0), 71 women (48.6%) had T1DM. DR and STDR prevalence during pregnancy per 100 eyes was 24.3 (95% CI 19.7-29.6) and 9.0 (95% CI 6.1-12.9); while prevalence in the postpartum was 22.2 (95% CI 16.5-29.3) and 10.0 (95% CI 5.4-17.9), respectively. T1DM, longer diabetes duration, higher HbA1c in early pregnancy, and pre-existing nephropathy were significant risk factors. CONCLUSIONS: The prevalence of DR in pregnant women was similar to the non-pregnant diabetic population in Australia. One in nine participants had STDR during pregnancy and the postpartum, highlighting the need to optimise DR management guidelines in pregnancy given the significant risk of vision loss.

Working with young people: evaluation of an education resource for medical trainees.

AIM: Many health professionals report interest in consulting more effectively with young people but have unmet training needs. We set out to evaluate a teaching resource in adolescent health and medicine that was designed for Australian trainees in specialist medicine. METHODS: Thirty-two paediatric and adult trainees of the Royal Australasian College of Physicians completed a pre-evaluation questionnaire to assess attitudes and confidence in working with young people. They were then provided with a training resource and, 6 weeks later, completed a post-evaluation questionnaire. Repeated-measures anovas were used to assess changes in attitudes, self-reported knowledge and confidence by trainee type. χ(2) -tests were used to compare variation in the use of and opinions about the resource. RESULTS: Trainees' awareness of the health issues that affect young people, confidence in working with young people and confidence in their knowledge greatly improved after using the resource. Beforehand, adult medicine trainees scored lower than paediatric trainees. A relatively higher rate of improvement resulted in similar scores between trainee types after using the resource, which was rated equally highly by the different groups of trainees. CONCLUSIONS: As a result of significant gains in the confidence of specialist medicine trainees after access to the resource, it will now be made available for Australian trainees in specialist medicine.

Gestational diabetes mellitus--negotiating the confusion.

BACKGROUND: Recommendations to change the diagnostic criteria for gestational diabetes mellitus (GDM) are controversial. Two sets of criteria are currently in use in Australia, which has led to considerable confusion. OBJECTIVE: This article discusses the rationale behind the proposed changes to the diagnostic criteria, and aims to clarify the current approach to the testing for and diagnosis of GDM in Australia. DISCUSSION: Gestational diabetes mellitus has adverse effects on pregnancy outcomes and implications for the long term wellbeing of mother and infant. New information about the relationship between hyperglycaemia in pregnancy and fetal outcomes has led to the formulation of revised recommendations for testing and diagnosis of GDM. The changes to the diagnostic threshold will increase the numbers of women diagnosed with GDM by up to 50%. Evidence that management of GDM improves neonatal outcomes mandates a proactive approach to diagnosis and management. General practitioners will have an increasing role in managing GDM.

Simulation in clinical teaching and learning.

Simulation-based education (SBE) is a rapidly developing method of supplementing and enhancing the clinical education of medical students. Clinical situations are simulated for teaching and learning purposes, creating opportunities for deliberate practice of new skills without involving real patients. Simulation takes many forms, from simple skills training models to computerised full-body mannequins, so that the needs of learners at each stage of their education can be targeted. Emerging evidence supports the value of simulation as an educational technique; to be effective it needs to be integrated into the curriculum in a way that promotes transfer of the skills learnt to clinical practice. Currently, SBE initiatives in Australia are fragmented and depend on local enthusiasts; Health Workforce Australia is driving initiatives to develop a more coordinated national approach to optimise the benefits of simulation.

Clinical teaching and learning: from theory and research to application.

Learning in the clinical setting is the cornerstone of medical school education, but there are strong imperatives to optimise the ways in which students acquire clinical expertise. Deliberate practice is characterised by attention, concentration, effort and repetition of skills; it is an important tool for developing and maintaining professional expertise. Research has led to a greater understanding of how medical students develop core clinical skills, especially in the areas of diagnostic reasoning, communication and physical examination. Advances in information technology and instructional design are helping to strengthen the links between formal educational activities and opportunistic learning in the clinical setting.

Paraganglioma in pregnancy: A case series and literature review.

Paragangliomas are rare neuroendocrine neoplasms which are often catecholamine-secreting and associated with familial syndromes. Described here are three women with a variety of pathology: isolated secretory paraganglioma diagnosed in pregnancy, secretory metastatic paraganglioma in pregnancy and non-secretory metastatic paraganglioma in pregnancy. Whilst paragangliomas are associated with morbidity and mortality during pregnancy, good maternal and fetal outcomes can be achieved through individualised care within the context of a multidisciplinary team. Although paragangliomas are associated with morbidity and mortality in pregnancy, good maternal and fetal outcomes can be achieved through individualised care within the context of a multidisciplinary team.

Glucose patterns following alcohol and illicit drug use in young adults with type 1 diabetes: A flash glucose monitoring study.

INTRODUCTION: To assess the effects of alcohol and illicit drug use in young adults (age 18-35) with type 1 diabetes (T1D) on flash glucose monitor sensor glucose (SG) readings. METHODS: Twenty young adults with T1D were enrolled from a tertiary referral hospital outpatient department in Melbourne, Australia for a 6-week prospective observational study using flash glucose monitoring (FGM). Glucometrics comparing substance using days (SUEDs) to those without substance use (non-SUEDS) were analysed. The primary outcomes were the difference in mean SG values, its standard deviation and minutes/24-h period out of range (SG <3.9 mmol/L or >10.0 mmol/L) between matched SUEDs vs non-SUEDs. An interaction model with the primary effect of HbA1c on SG values was also performed. RESULTS: There were no differences in the primary outcome measures between SUEDS and non-SUEDs. However, there were differences in the regression coefficients for HbA1c and glucometrics between non-SUEDs and SUEDs for mean SG, time out of range and time with SG > 10 mmol/L. This difference was also identified between non-SUEDS and days of ≥40 g alcohol for mean SG. CONCLUSIONS: While there was no difference between glucometrics for SUEDs and non-SUEDs on primary outcomes, HbA1C was found to be a less reliable predictor of glucose patterns in the 24-h period following substance use than control days. Young adults with T1D need to monitor and respond to their glucose levels following substance use and engage in harm minimisation practices irrespective of baseline glucose control.

Comparing the academic performance of graduate- and undergraduate-entry medical students.

OBJECTIVE: This study compared the academic performance of graduate- and undergraduate-entry medical students completing the same pre-clinical curriculum and assessment at a large metropolitan university. Arguments have been made for the relative merits of both graduate- and undergraduate-entry medical programmes. However, data on the academic performance of graduate and undergraduate entrants are relatively scarce. METHODS: This retrospective study adopted a quasi-experimental design to compare data from assessments of bioscience knowledge and clinical skills undertaken across 2 years for four cohorts of medical students (who commenced their studies between 2002 and 2005). Percentage final results for four bioscience knowledge subjects and four clinical skills assessments (based on objective structured clinical examination [OSCE] results) were compared for 240 graduates and 464 undergraduates using multivariate analysis of variance (manova). RESULTS: Graduate-entry students performed marginally better than undergraduate-entry students on all four bioscience knowledge assessments (partial eta-squared [n(p)(2)], n(p)(2)=0.04) and also on early clinical skills assessments (n(p)(2)=0.06). CONCLUSIONS: Graduate-entry students had a marginal academic performance advantage during the early years of this medical course. Most graduate-entry students had a first degree in a science discipline; thus their advantage may be explained by prior bioscience knowledge. Their performance advantage in clinical skills is less easily attributed to prior learning. Instead, this result provides some evidence for a possible advantage related to age. The marginal differences in early academic and clinical performance probably suggest that both graduate and undergraduate entry should exist in parallel to preserve multiple points of entry to the medical profession.

Alcohol and illicit drug use in people with diabetes.

As the prevalence of type 1 and type 2 diabetes increases and population-level patterns of alcohol and illicit drug use evolve, clinicians will continue to encounter people with diabetes whose substance use is affecting health outcomes. Substance use contributes substantially to the population-level prevalence of cardiovascular events, cerebrovascular events, cancers, mental health conditions, road trauma, and domestic violence. Alcohol and drug use also have a measurable effect on diabetes incidence and the development of both acute and chronic diabetes-related complications. In this Review, we examine the effect of alcohol and illicit drug use on people with type 1 or type 2 diabetes. We describe evidence for substance use as a risk factor for new-onset diabetes, prevalence of use in people with diabetes, evidence linking substance use with diabetes-related health outcomes, and evidence on the management of these co-occurring conditions.

Food and nutrient intakes of 9-month-old infants in Adelaide, Australia.

OBJECTIVE: To describe the food and nutrient intakes of 9-month-old infants. DESIGN: A survey undertaken as part of a longitudinal study of child growth and development. Infant diet was characterised through a structured interview in which consumption frequency and portion size of foods were obtained. This method was compared with a 4 d diary and had adequate relative validity. SETTING: Adelaide, Australia. SUBJECTS: Three hundred and forty-one infants for whom dietary data were plausible according to pre-specified criteria. RESULTS: At 9 months of age, the median body weights for 161 girls and 180 boys were 8.8 and 9.6 kg, respectively. Differences in intakes between boys and girls largely reflected differences in size. Median daily energy intake was 3541 kJ and median contributions of protein, fat and carbohydrate to total energy were 13 %, 36 % and 50 %. Using published Estimated Average Requirements, Zn intake was inadequate for <1 % of children not breast-fed at this age while Fe intake was inadequate for 9 %. Infants who were still breast-fed (35 %) had more diversity in the foods that provided additional energy, compared with those not receiving breast milk, and were less likely to consume nutrient-displacing drinks such as juice or cordial. Cow's milk was the main drink for 5 % of infants. CONCLUSIONS: In a group of Australian-born children, an important proportion had weaning diets that were low in Fe. Fat intake of many children was below current recommendations and cow's milk was the main milk source for a small minority.

Neonatal hyperinsulinaemic hypoglycaemia and monogenic diabetes due to a heterozygous mutation of the HNF4A gene.

Recent research has demonstrated that mutations of the hepatocyte nuclear factor 4-alpha (HNF4A) gene are associated with neonatal hyperinsulinaemic hypoglycaemia. Mutations of this gene also cause one of the subtypes of monogenic diabetes, a form of diabetes formerly known as maturity-onset diabetes of the young. This article describes a family discovered to have a novel frame-shift mutation of the HNF4A gene in the setting of early-onset maternal diabetes and severe neonatal hyperinsulinaemic hypoglycaemia. The implications of a diagnosis of HNF4A gene mutation for obstetric and paediatric practice are discussed.

Gestational diabetes mellitus: A pragmatic approach to diagnosis and management.

BACKGROUND: Gestational diabetes mellitus (GDM) is a common condition with risks for mother and baby. Type 2 diabetes mellitus (T2DM) and obesity are occurring with increasing frequency, and the incidence of GDM reflects this trend. Further, new diagnostic criteria have greatly increased the prevalence of GDM. Potential lifelong consequences exist for mother and baby if the condition goes untreated; however, adverse maternal and fetal effects can be ameliorated by effective pregnancy management. OBJECTIVE: The aim of this article is to provide practical advice regarding GDM diagnosis, management and postpartum follow-up for general practitioners, who, increasingly, will be involved in GDM care. DISCUSSION: Controversy surrounds many aspects of GDM. Recommendations are frequently based on consensus. In the context of a deficient evidence base, any recommendations are open to debate. However, it is reasonable to suggest a pragmatic way forward, maintaining an open mind about the current diversity of practice and a preparedness to include further research findings into future practice.

Experiences of young adults with type 1 diabetes while using alcohol and recreational drugs: An interpretative phenomenological analysis (IPA) of semi-structured interviews.

AIMS: Alcohol and recreational drug use is common in young adults with type 1 diabetes (T1DM) and may account for increased morbidity and mortality. This study explores the motivations and experiences unique to this population while using alcohol and recreational drugs. METHODS: Semi-structured interviews focusing on substance use were performed with 16 young adults aged 18-35 with T1DM who drink alcohol (at least 50 g, 5 Australian standard drinks, in a single session) and/or used recreational drugs. A qualitative interpretative phenomenological analysis (IPA) of the interview data was performed by three clinicians with differing expertise (a psychologist, endocrinologist and addiction medicine specialist). RESULTS: A range of motivations, experiences and harm reduction strategies regarding substance use were described specific to young adults with T1DM with most aimed at mitigating the risk of hypoglycaemia. Clinicians remained the most trusted resources, however, substance use was rarely discussed at clinical encounters. Currently available information, especially for illicit drugs, was described as inadequate. CONCLUSIONS: This analysis identified experiences unique to young adults with T1DM when using alcohol and other drugs. Understanding these experiences and how these young adults attempt to mitigate the risks of substance use may lead to improved clinical interactions and management strategies.

A training agenda in adolescent medicine and health.

The complexity of health issues facing young people, an appreciation that problems arising in adolescence may have long term implications for health, and greater confidence about the value of clinical intervention are key factors underpinning current efforts in Australia to build an education agenda for health professionals working with young people. This paper outlines a series of education initiatives in both undergraduate and postgraduate settings and discusses the growing support for more strategic and coherent approaches to education nationally. In particular, efforts to improve the capacity of health professionals to work with young people are described, together with the opportunity for more focused subspeciality training in Adolescent Medicine. Within our region and beyond, Australia is increasingly being turned to as a model of academic leadership in adolescent medicine, including professional education and training. In Australia, this has been best achieved by centres of excellence in adolescent health.

Alcohol and recreational drug use in young adults with type 1 diabetes.

Alcohol and other recreational drug use reaches peak prevalence in young adulthood, including for those with chronic medical conditions such as type 1 diabetes. This review summarises the current literature on the patterns of substance use amongst young adults with type 1 diabetes and the mechanisms through which alcohol and recreational drugs may affect diabetes related health outcomes. These include the direct physical effect of intoxication, as well as the effects of alcohol and drugs on mental health and glucose metabolism. Evidence for increased associated mortality and morbidity is also presented, and current guidelines, management strategies and directions for further research are discussed.

Psychosocial influences on glycemic control in women with pre-existing diabetes preparing for pregnancy.

OBJECTIVE: The purpose of this study was to identify psychosocial factors associated with glycemic control in a sample of adult women with type 1 or type 2 diabetes mellitus preparing for pregnancy. METHODS: This was a cross-sectional study. Participants comprised a subsample (n=38) of a larger study investigating predictors of prepregnancy care uptake in women with pre-existing diabetes. Participants were recruited from the diabetes and pregnancy clinics at 2 major hospitals and completed self-report questionnaires on personality, coping style, social support and knowledge of diabetes and pregnancy. The main outcome was glycemic control using glycated hemoglobin (A1C) as the outcome of interest. RESULTS: The sample was divided into good (n=20) vs. poor (n=18) glycemic control based on their A1C at entry to the study. Univariate tests indicated no differences between the 2 groups on any of the variables except that the good control group were better educated. Hierarchical multiple regression analysis revealed that problem-focused coping and higher education remained significantly associated with better glycemic control when controlling for potential confounds. CONCLUSIONS: Providing women with enhanced prepregnancy diabetes education with a particular emphasis on problem-solving and coping skills may enable them to take more proactive approaches to challenges they face in managing their diabetes. That in turn can improve glycemic control at the critical period.

Building capacity in medical education research in Australia.

Medical education research is a relatively new but growing discipline. There is an overall perception of lack of confidence in the quality of the research, which is not entirely justified. The scientific quality of any research is defined by the appropriate application of method to a particular problem. There is a need for programmatic research focused on developing medical education policy. University medical education units need to be research-focused. Medical Deans Australia and New Zealand and the Australian and New Zealand Association of Medical Education (ANZAME: the Association for Health Professional Education) can provide leadership. Funding bodies need to develop their relationship with medical education research.