Negotiating Gestational Diabetes Mellitus in India: A National Approach.

The worldwide epidemic of diabetes mellitus and hyperglycemia in pregnancy (HIP) presents many challenges, some of which are country-specific. To address these specific problems, parochial resolutions are essential. In India, the government, by working in tandem with (a) national groups such as the Diabetes in Pregnancy Study Group of India, and (b) global organizations such as the International Diabetes Federation, has empowered the medical and paramedical staff throughout the country to manage HIP. Additionally, despite their academic university backgrounds, Indian health planners have provided practical guidelines for caregivers at the ground level, who look up to these experts for guidance. This multipronged process has helped to negotiate some of the multiple problems that are indigenous and exclusive to India. This review traces the Indian journey to manage and prevent HIP with simple, constructive, and pragmatic solutions.

A survey of retaining faculty at a new medical school: opportunities, challenges and solutions.

BACKGROUND: At well-established academic university settings, retaining faculty remains a pressing challenge due to competing market forces, decreasing institutional support, and changing personal expectations. There is a paucity of information about the difficulties faced by new medical schools to maintain their academic workforce. The objective of this study was to determine the challenges facing the faculty at a newly developed medical school. METHODS: Twelve founding faculty were surveyed anonymously by a 32-item questionnaire. Their responses were independently analyzed by three researchers. RESULTS: The views of the faculty were categorized into in four inter-related themes: personal, support, institutional, and environmental. The constant sources of satisfaction among faculty were higher academic rank (75%), harmonious inter-collegial relationships (74%), healthy pecuniary rewards (58%), better professional growth (58%) along with greater autonomy, administrative independence, minimum groupism and excellent team work. Poor opportunities for promotion (68%), reduced support for scholarly activities (67%) and unsatisfactory support from the administration (55%) were detrimental to retaining faculty. CONCLUSION: By addressing specific issues facing its staff, every new medical school will not only manage to retain its academic faculty but also be able to attract well qualified academic staff from established medical institutions worldwide.

Breast cancer protection by genomic imprinting in close kin families.

Human inbreeding generally reduces breast cancer risk (BCR). When the parents are biologically related, their infants have a lower birth weight due to smaller body organs. The undersized breasts, because of fewer mammary stem cells, have a lower likelihood of malignant conversion. Fetal growth is regulated by genomically imprinted genes which are in conflict; they promote growth when derived from the father and suppress growth when derived from the mother. The kinship theory explicates that the intensity of conflict between these genes affects growth and therefore the size of the newborn. In descendants of closely related parents, this gene clash is less resulting in a smaller infant. In this review, we elucidate the different mechanisms by which human inbreeding affects BCR, and why this risk is dissimilar in different inbred populations.

Gestational diabetes mellitus: Confusion among medical doctors caused by multiple international criteria.

AIM: The aim of this study was to appraise the current regional practices of screening, diagnosis and follow-up of gestational diabetes mellitus (GDM) because the approach to GDM is frequently inconsistent. MATERIAL AND METHODS: A 21-item questionnaire was distributed to physicians taking care of pregnant women in seven hospitals in the United Arab Emirates and one hospital in Oman. Besides assessing their attitudes towards testing for GDM, the questionnaire assessed familiarity with the Hyperglycemia and Pregnancy Outcome study and the International Association of Diabetes in Pregnancy Study Groups GDM guidelines. RESULTS: One hundred and forty-eight (93%) of the 159 questionnaires distributed to the medical doctors (106 [72%] obstetricians and 42 [28%] internists) were returned. For GDM screening, six hospitals used five different tests; two hospitals utilized one single test. For GDM diagnosis, six hospitals employed the 2-h, 75-g oral glucose tolerance test (OGTT) (four different criteria) while two hospitals used the 3-h, 100-g OGTT (single criteria). For post-delivery follow-up, the 2-h, 75-g OGTT and fasting plasma glucose were accepted by 103 (70%) and 38 (26%) of the 148 medical doctors, respectively. Ninety-eight (69%) of 143 responding physicians were aware of the Hyperglycemia and Pregnancy Outcome study, while 85 (61%) of 140 responders were familiar with the guidelines of the International Association of Diabetes in Pregnancy Study Groups; this knowledge was independent of specialty, seniority, academia, years in practice or country trained. CONCLUSIONS: Although this study is parochial, its implications are global; that is, further education of caregivers would make the discordant approach to GDM (within and between hospitals) more harmonious and improve the obstetric care of pregnant women.

Gestational diabetes in a tertiary care hospital: implications of applying the IADPSG criteria.

BACKGROUND: The American Diabetes Association has endorsed the International Association of Diabetes and Pregnancy Groups (IADPSG) recommendation that every pregnant woman should undergo the 75 g oral glucose tolerance test (OGTT) to screen for gestational diabetes mellitus (GDM). PURPOSE: To find the cost and workload implications of switching from the current two-step screening of GDM to the one-step IADPSG approach. METHODS: The cost (US $) and laboratory workload units (WLU) were calculated for three possible strategies: (1) 50 g glucose screen, if positive, followed by the 100 g OGTT; (2) universal 75 g OGTT; and (3) screening with the initial fasting plasma glucose of the OGTT. RESULTS: For the 1,101 pregnant women screened in 1 year, the cost of the three strategies was $ 31,985, $ 55,250 and $ 35,875, respectively; the laboratory burden was 28,975 WLU, 18,662 WLU and 12,215 WLU, respectively. CONCLUSIONS: Switching to the one-step, strategy 2 (IADPSG) would increase the cost by 42 % but decrease the laboratory workload by 36 % compared to the two-step, strategy 1. However, an initial screen by the fasting plasma glucose of the OGTT is the ideal strategy, both in terms of cost and laboratory workload.

Gestational Diabetes Mellitus in a Multi-Ethnic, High-Risk Population: Adequacy of Screening for Diabetes Mellitus 6 Weeks after Delivery.

Gestational diabetes mellitus (GDM) during pregnancy is a marker for future type 2 diabetes mellitus (T2DM); therefore, a meticulous follow-up after delivery can help identify women at risk for T2DM. In a cohort of 5504 pregnant women, the postpartum follow-up of all 1043 women with GDM for hyperglycemia in a multi-ethnic, high-risk Arab population was investigated. The prevalence of GDM was 18.9%. A total of 265 (25.4%) women returned for an oral glucose tolerance test (OGTT) 4-6 weeks after delivery, with more South Asian than Arab women (p < 0.01). The other factors associated with return were (a) family history of T2DM, (b) lower basic metabolic index, (c) higher abortions and (d) lower gravida (p < 0.05), all with minimal effect. An abnormal postpartum OGTT was statistically associated with previous GDM history and hypoglycemic drug treatment, although these effects were small. Overall, the follow-up of women with GDM postpartum was dismal, ethnicity being the major factor influencing return. Urgent public measures are needed to educate women with GDM about follow-up highlighting (a) risk awareness for T2DM and (b) a healthy lifestyle after childbirth-if we are to turn the tide on the epidemic of T2DM plaguing the Arab world.

Gestational diabetes: an evaluation of serum fructosamine as a screening test in a high-risk population.

AIM: To evaluate the value of serum fructosamine as a screening test for gestational diabetes mellitus (GDM). METHODS: 849 pregnant women underwent the one-step 75 g oral glucose tolerance test (OGTT) for universal screening of GDM. The fasting serum fructosamine (cFruc) was assessed using the area under the receiver operating characteristic curve (AUC). The GDM diagnostic criteria used were those of the American Diabetes Association; however, the cFruc performance was also evaluated using criteria of the World Health Organization, Australian (ADIPS), European (EASD) and International Association of Diabetes and Pregnancy Study Groups (IADPSG). RESULTS: 113 (13.3%) women had GDM. The AUC of the cFruc was 0.60 (95% CI 0.54-0.66). A cFruc threshold of 237 µmol/l achieved an acceptable sensitivity of 85.8% (95% CI 78.0-91.0%), but the associated specificity remained poor at 23.4% (95% CI 20.0-27.0%) with a positive predictive value of just 14.7%. Overall, over 4 out of 5 pregnant women, being over this cutoff, would need the confirmatory OGTT. No cFruc threshold reached acceptable likelihood ratios to rule-in or rule-out GDM. The AUC for cFruc remained unacceptable independent of the diagnostic criteria. CONCLUSIONS: Despite all the advances in technology, serum fructosamine is a poor test to screen for GDM.

Altruism as an Explanation for Human Consanguinity.

BACKGROUND: Human inbreeding is a sociobiological puzzle. Despite widespread knowledge of its potential for genetic disorders, human consanguinity remains surprisingly common. The current reasons explaining its continued persistence in today's modern world have major shortcomings. SUMMARY: We propose that the Neolithic Agrarian revolution modified the structure of populations. It increased competition for the limited resources in which a larger group had better chances of survival. As a result, small, drifting, socially open bands of hunter-gatherers were transformed into bigger, less mobile, and more powerful kinship groups (tribes). In this transformation, a central role was played by human trust - an aspect of human altruism which is a universal sociobiological principle of behavior. Altruism (and trust) is an essential premise of social contracts such as economic cooperation, marriage arrangement, and creation of alliances between people. In kinship groups, human trust is limited to kin, so tribes remain small, economically poor, and consanguineous due to lack of nonkin mates. The expanding of trust from kin to that of nonbiological relatives increases the size of human groups, fosters economic wealth, and decreases the rate of consanguinity. Key Messages: The lack of nonkin altruism leads to: (a) poverty (due to poor economic cooperation with nonkin), (b) maintaining small group size, and (c) inbreeding.

Choice of kin in consanguineous marriages: effects of altruism and ecological factors.

BACKGROUND: Despite being associated with multiple genetic problems, consanguineous marriages continue to remain extremely prevalent worldwide. Studying the variation of kin preferences in diverse inbred societies may provide some answers to this paradox. AIM: To find the reasons for specific kin choice in different geographical areas of the world. METHOD: We used a set of sociobiological rules (kin altruism, sexuality and inbreeding avoidance) and ecological constraints (e.g. tribal warfare, food availability) that influence human behaviour. The cumulative help that the extended family can provide to a nuclear family was calculated using the coefficient of relatedness between kin in different types of consanguineous families. RESULTS: The maximum potential support for kin markedly varied between different types of consanguineous marriages. Overall, members of consanguineous families received up to two-and-half times more support than members of non-consanguineous families. In various inbred cultures, preference for a specific type of kin was determined by prevailing ecological limitations and sociobiological factors interacting in a complex manner. CONCLUSION: In different inbred populations, the ideal kin for a consanguineous marriage is the one who can provide the most altruistic support; however, this choice is influenced by biological rules of behaviour and ecological constraints.

Gestational Diabetes in the Arab Gulf Countries: Sitting on a Land-Mine.

Type 2 diabetes mellitus (T2DM) has become a modern-day plague by reaching epidemic levels throughout the world. Due to its similar pathogenesis, gestational diabetes (GDM) increases in parallel to T2DM. The prevalence of T2DM (3.9-18.3%) and GDM (5.1-37.7%) in countries of the Arab Gulf are amongst the highest internationally, and they are still rising precipitously. This review traces the reasons among the Arab nations for (a) the surge of T2DM and GDM and (b) the failure to contain it. During the last five decades, the massive oil wealth in many Arab countries has led to the unhealthy lifestyle changes in physical activity and diet. The excess consumption of calories turned the advantageous genes, originally selected for the famine-like conditions, detrimental: fueling obesity and insulin resistance. Despite genetic differences in these populations, GDM-a marker for future obesity and T2DM-can overcome this scourge of T2DM through active follow-up and screening after delivery. However, the health policies of most Arab countries have fallen short. Neglecting this unique chance will miss an irreplaceable opportunity to turn the tide of the T2DM and obesity epidemic in the Middle Eastern Arab Gulf countries-as well as globally.

Prevalence, phenotype and inheritance of benign neutropenia in Arabs.

BACKGROUND: Benign neutropenia, i.e., neutropenia not associated with an increased risk of infection, may result in serious medical consequences when a 'standard' definition of neutropenia (absolute neutrophil count (ANC) < 1.5 x 10(9)cells/L) is universally applied to all races. The aims of this study were to determine the prevalence of benign neutropenia among healthy Arabs and evaluate its mode of inheritance. METHODS: ANCs were studied prospectively amongst a healthy indigenous population (n = 1032) from the United Arab Emirates undergoing a nation-wide sickle-cell and thalassemia screening program. The mean neutrophil count and the prevalence of benign neutropenia were compared by age, sex and amongst various tribes. RESULTS: The mean neutrophil count (x 10(9)cells/L) was 3.3 (range 0.95-7.6). Benign neutropenia was present in 110 (10.7%) subjects of whom 24 (2.3%) individuals had moderate neutropenia (ANC 0.5 - 1.0 x 10(9) cells/L). In the 22 tribe-family groups, the prevalence of benign neutropenia varied between 0% and 38%. Benign neutropenia showed no difference in the frequency amongst the sexes (p = 0.23) and it was independent of age (Spearman's rho = 0.05, p = 0.13). The age-related mean neutrophil count was the lowest in Arabs when compared with other ethnic groups (Blacks, Europeans and Mexicans). The inheritance of benign neutropenia was consistent with an autosomal dominant pattern; however, the diversity of observed phenotypes suggested the presence of more than one genetic variant for this trait. CONCLUSION: Arabs have a high prevalence of benign neutropenia that may be inherited as an autosomal dominant trait.

Consanguineous marriages and endemic malaria: can inbreeding increase population fitness?

BACKGROUND: The practice of consanguineous marriages is widespread in countries with endemic malaria. In these regions, consanguinity increases the prevalence of alpha+-thalassemia, which is protective against malaria. However, it also causes an excessive mortality amongst the offspring due to an increase in homozygosis of recessive lethal alleles. The aim of this study was to explore the overall effects of inbreeding on the fitness of a population infested with malaria. METHODS: In a stochastic computer model of population growth, the sizes of inbred and outbred populations were compared. The model has been previously validated producing results for inbred populations that have agreed with analytical predictions. Survival likelihoods for different alpha+-thalassemia genotypes were obtained from the odds of severe forms of disease from a field study. Survivals were further estimated for different values of mortality from malaria. RESULTS: Inbreeding increases the frequency of alpha+-thalassemia allele and the loss of life due to homozygosis of recessive lethal alleles; both are proportional to the coefficient of inbreeding and the frequency of alleles in population. Inbreeding-mediated decrease in mortality from malaria (produced via enhanced alpha+-thalassemia frequency) mitigates inbreeding-related increases in fatality (produced via increased homozygosity of recessive lethals). When the death rate due to malaria is high, the net effect of inbreeding is a reduction in the overall mortality of the population. CONCLUSION: Consanguineous marriages may increase the overall fitness of populations with endemic malaria.

Gestational diabetes: using a portable glucometer to simplify the approach to screening.

BACKGROUND: In populations at a high-risk for gestational diabetes (GDM), the recommendation of screening every pregnant woman with the oral glucose tolerance test (OGTT) is very demanding. AIM: To assess the usefulness of the portable, plasma optimized glucometer in simplifying the approach to screening of GDM. METHODS: 1,662 pregnant women underwent the one-step 75 g OGTT for routine screening of GDM, as defined by the criteria of the American Diabetes Association. The glucometer was used to measure the initial fasting venous whole blood glucose (FBG) to assess its value as a screening test in predicting the need to proceed with the OGTT. RESULTS: 186 (11.2%) women had GDM. The area under the receiver operating characteristic curve (AUC) of the FBG was 0.876 (95% CI 0.847-0.906). A FBG threshold (at an acceptable sensitivity of 85%) independently could 'rule-out' GDM in 1,138 (68.5%) women; i.e. over two-thirds of the women would not need to continue with the cumbersome OGTT. CONCLUSIONS: Using the glucometer to initially measure the venous FBG as a screen can help to significantly reduce the number of OGTTs needed for the diagnosis of GDM. This algorithm offers a simple, practical, cost-effective and patient-friendly approach for the screening of GDM.

Consensus in Gestational Diabetes MELLITUS: Looking for the Holy Grail.

The world's pre-eminent diabetes, obstetric, endocrine, and health organizations advocate a plethora of diverse algorithms for the screening, diagnosis, management, and follow-up of gestational diabetes mellitus (GDM). Additionally, there are regional recommendations of local health societies. Several of these proposals for GDM are contentious because some of them were developed from unscientific studies, based on expert-opinion, catered to preserve resources, and subjectively modified for convenience. Due to the wide variety of choices available, the approach to GDM can be extremely diverse even within the same hospital. This lack of consensus creates major problems in addressing prevalence, complications, efficacy of treatment, and follow-up of GDM. Moreover, it becomes nearly impossible to compare the numerous studies. Furthermore, the lack of consensus confuses the health care providers of obstetric health who look to the experts for guidance. Therefore, a clear, objective, "evidence-based" global approach, which is simple, easy to follow, and validated by corroborative research, is crucial. We contend that, despite decades of research, a single acceptable global guideline is not yet on the horizon.

Gestational Diabetes Mellitus: Using the Fasting Plasma Glucose Level to Simplify the International Association of Diabetes and Pregnancy Study Groups Diagnostic Algorithm in an Adult South Asian Population.

OBJECTIVES: To evaluate the value of the fasting plasma glucose (FPG) level for simplifying the International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic algorithm of gestational diabetes mellitus (GDM) in a South Asian population. METHODS: In 6,520 pregnant women undergoing universal screening with the 75 g oral glucose tolerance test (OGTT), the area under receiver operating characteristic curve was used to determine the overall FPG performance to detect GDM (IADPSG criteria). Specifically, 2 different FPG thresholds of the OGTT were used to rule in and rule out GDM so as to decrease the need for the cumbersome OGTT. RESULTS: GDM was present in 1,193 (18.3%) women. The FPG 1) area under receiver operating characteristic curve (95% CI) was 0.909 (0.898 to 0.920); 2) threshold of ≥5.1 mmol/L independently could rule in GDM in 708 (10.9%) women (100% specificity); 3) threshold of <4.3 mmol/L independently could rule out GDM in an additional 2,389 (36.6%) women (95.6% sensitivity). CONCLUSIONS: By circumventing nearly one half the OGTTs, an initial FPG can simplify the onerous GDM diagnostic IADPSG algorithm in this population parochially and in countries with large South Asian immigrant populations-without compromising medical care.

Nutritional iron deficiency: an evolutionary perspective.

Iron deficiency, with or without iron-deficiency anemia, is so ubiquitous that it affects all populations of the world irrespective of race, culture, or ethnic background. Despite all the latest advances in modern medicine, improved nutrition, and the ready availability of cheap oral iron, there is still no good explanation for the widespread persistence of iron deficiency. It is possible that the iron deficiency phenotype is very prevalent because of many factors other than the commonly cited causes such as a decreased availability or an increased utilization of iron. Several thousand years ago, human culture changed profoundly with the agrarian revolution, when humans turned to agriculture. Their diet became iron deficient and new epidemic infections emerged due to crowding and lifestyle changes. There is convincing evidence that iron deficiency protects against many infectious diseases such as malaria, plague, and tuberculosis as shown by diverse medical, historical, and anthropologic studies. Thus, this change of diet increased the frequency of iron deficiency, and epidemic infections exerted a selection pressure under which the iron deficiency phenotype survived better. Multiple evolutionary factors have contributed in making iron deficiency a successful phenotype. We analyze some of the recent findings of iron metabolism, the theories explaining excessive menstruation in human primates, the unexplained relative paucity of hemochromatosis genes, the former medical practice of "blood-letting," and other relevant historical data to fully understand the phenomenon of iron deficiency. We suggest that, due to a long evolutionary persistence of iron deficiency, efforts at its prevention will take a long time to be effective.

Gestational diabetes: fasting and postprandial glucose as first prenatal screening tests in a high-risk population.

OBJECTIVE: To evaluate the value of fasting (FPG) and 2-hour postprandial (PPG) plasma glucose as screening tests for gestational diabetes mellitus (GDM) in a high-risk population during early pregnancy. STUDY DESIGN: At their first prenatal visit, 708 women underwent FPG and PPG for universal screening for GDM, with the diagnosis confirmed by the 75-g oral glucose tolerance test (World Health Organization criteria). The area under the receiver operating characteristic curve (AUC) was used to analyze the performance of the 2 screening tests. RESULTS: Of 184 (25.9%) women with GDM, 79 (42.9%) were identified before 18 weeks. The AUC for FPG to predict GDM was 0.579 (95% CI 0.531-0.627). Though a threshold of 85 mg/dL achieved minimally acceptable sensitivity, 79.9%, the corresponding specificity remained poor, 27.5%, with a false positive rate (FPR) of 72.5%. The AUC for PPG was 0.717 (95% CI 0.670-0.765); a cutoff of 95 mg/dL achieved a sensitivity of 79.9% and FPR of 53.1%. CONCLUSION: Though GDM could be diagnosed in > 40% women in early pregnancy at their first prenatal visit, the poor specificity and high FPR of FPG and PPG, alone or in combination, make them unsuitable screening tests for GDM.

Thyroid hormone reference intervals in an ambulatory Arab population on the Abbott Architect i2000 immunoassay analyzer.

BACKGROUND: Considerable differences in reference intervals for FT4 and TSH have been reported between countries. Method related differences in the distribution of free thyroxine (FT4) have also been reported. The aim of this study was to establish reference intervals for thyrotrophin (TSH) and FT4 in an ambulatory adult (16-75 y) Arab population attending a general practice clinic using the Abbott Architect i2000 immunoassay analyzer. METHODS: TSH and FT4 results from 959 consecutive ambulatory Arab subjects were available. After excluding data sets from pregnant women, patients with known and newly diagnosed thyroid disease, individuals taking medication that may affect TSH and FT4 and individuals with acute illness, 742 data sets were available for analysis. A 2-way between-groups ANOVA was conducted to explore the impact of age and gender on TSH and FT4. RESULTS: TSH showed a non-Gaussian distribution, FT4 showed a near normal distribution. There was no significant main effect on FT4 and TSH for age and gender. The interaction effect of age and gender also did not reach significance. The 95% reference intervals were: TSH 0.30-4.32 mU/l and FT4 9.8-18.6 pmol/l. The reference intervals for TSH and FT4 determined in this study differed from those reported from other countries using the same analytical platform and from the 99% reference intervals, provided by the manufacturer. CONCLUSIONS: These differences in reference intervals in different populations may affect patient management. The data reported reemphasize that each laboratory should determine population and method-specific reference intervals.

Gestational diabetes mellitus: Screening with fasting plasma glucose.

Fasting plasma glucose (FPG) as a screening test for gestational diabetes mellitus (GDM) has had a checkered history. During the last three decades, a few initial anecdotal reports have given way to the recent well-conducted studies. This review: (1) traces the history; (2) weighs the advantages and disadvantages; (3) addresses the significance in early pregnancy; (4) underscores the benefits after delivery; and (5) emphasizes the cost savings of using the FPG in the screening of GDM. It also highlights the utility of fasting capillary glucose and stresses the value of the FPG in circumventing the cumbersome oral glucose tolerance test. An understanding of all the caveats is crucial to be able to use the FPG for investigating glucose intolerance in pregnancy. Thus, all health professionals can use the patient-friendly FPG to simplify the onerous algorithms available for the screening and diagnosis of GDM - thereby helping each and every pregnant woman.

HbA1c: a comparison of NGSP with IFCC transformed values.

BACKGROUND: An approved IFCC reference method for measuring HbA1c, with a firm and reproducible correlation with NGSP values, is now available. We established (i) the degree of agreement of HbA1c results between the NGSP-certified and the IFCC-calibrated (converted to NGSP values) immunochemical method and (ii) the difference in the classification of control of diabetes mellitus (DM) in individual patients between the methods. METHODS: HbA1c was measured on the same hemolysate from each patient by both methods (n=92). Results were analyzed by the kappa statistic, linear regression, and McNemar's chi(2) test. RESULTS: Both methods achieved acceptable analytical performance. The kappa statistic measure of agreement was 0.65 and r(2)=0.937. Overall, 21 (22.8%) patients were classified differently in the extent of diabetes control (good, acceptable, or poor), with a significant difference between the 2 methods (p<0.0005). CONCLUSIONS: The IFCC converted to NGSP values were significantly different from the previously used NGSP-certified method. The differences between the 2 methods are of sufficient magnitude that HbA1c results from these methods are not interchangeable. The IFCC method being scientifically superior in concept and design should replace the NGSP method. New HbA1c targets for DM management need to be established for the IFCC method.