Hemoglobin A1c as a Substitute for Oral Glucose Testing in Early Pregnancy Screening.

OBJECTIVE: Current recommendations for individuals with risk factors for gestational diabetes mellitus (GDM) call for screening in early pregnancy. However, there is currently no clear consensus on a specific screening modality. This study evaluates whether a hemoglobin A1c (HbA1c) screening in individuals with risk factors for gestational diabetes (GDM) could be used instead of an early 1-hour glucose challenge test (GCT). We hypothesized that the HbA1c could replace 1-hour GCT in early pregnancy evaluation STUDY DESIGN: This is a prospective observational trial at a single tertiary referral center of women with at least one risk factor for GDM who were screened at <16 weeks of gestation with both 1-hour GCT or HbA1c. Exclusion criteria include: previous diagnosis of diabetes mellitus, multiple gestation, miscarriage, or missing delivery information. The diagnosis of GDM was made by a 3-hour 100-g glucose tolerance test, using the Carpenter-Coustan criteria (at least two results >94, 179, 154, and 139 mg/dL for fasting, 1-, 2-, and 3-hour values, respectively), 1-hour GCT > 200 mg/dL, or HbA1c > 6.5%. RESULTS: A total of 758 patients met inclusion criteria. A total of 566 completed a 1-hour GCT and 729 had an HbA1c collected. The median gestational age at testing was 91/7 weeks (range: 40/7-156/7 weeks]. Twenty-one participants were diagnosed with GDM at <16 weeks' GA. The receiver operating characteristic (ROC) curves identified the optimal valves for a positive screen for an HbA1c > 5.6%. The HbA1c had a sensitivity of 84.2%, a specificity of 83.3%, and a false positive rate of 16.7% (p < 0.001). The area under the ROC curve for the HbA1c was 0.898. Gestational age of delivery was slightly earlier with individuals with an elevated HbA1c but no other changes in delivery or neonatal outcomes. Contingent screening improved specificity (97.7%) and decreased false positive rate to 4.4%. CONCLUSION: HbA1c may be a good assessment in early pregnancy for gestational diabetes. KEY POINTS: · HbA1c is a rational assessment in early pregnancy.. · An HbA1c > 5.6% is associated with gestational diabetes.. · Contingent screening limits the need for additional testing..

Third Trimester Ultrasound Stratifies Risk of Peripartum Complications in Pregnancies Complicated by Impaired Glucose Tolerance.

OBJECTIVE: The objective of our study was to investigate the effect of impaired glucose metabolism (IGM) and ultrasound (US) findings consistent with hyperglycemia on maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective case-control study of singleton, nonanomalous pregnancies with an elevated 1-hour glucose screening test (GST) completed after 23 weeks of gestation. IGM was defined as a 1-hour GST of >130, but less than two abnormal values on 3-hour glucose tolerance test (GTT). Gestational diabetes was defined as two or more abnormal values on 3-hour GTT. Ultrasound evidence of hyperglycemia was defined as abdominal circumference >95th centile and/or polyhydramnios. Individuals with IGM were divided into those with ultrasound evidence of hyperglycemia (impaired glucose metabolism consistent with ultrasound findings [IGM-US]) and those without IGM. Maternal demographics, delivery outcomes (gestational age at delivery, delivery mode, shoulder dystocia, lacerations), postpartum hemorrhage, and neonatal outcome (birth weight centile [BW%], neonatal intensive care unit admission, hypoglycemia, and glucose) were recorded. Composite morbidity was tabulated. Delivery and neonatal outcome variables were compared in individuals with IGM-US, IGM, and gestational diabetes mellitus (GDM). Odds ratios were calculated and adjusted for maternal age, BMI, and gestational weight gain. RESULTS: A total of 637 individuals with an abnormal 1-hour GST were included (122 with IGM-US, 280 with IGM, and 235 with GDM). When compared to the IGM group, IGM-US had higher rates of cesarean delivery and BW% > 90th centile at delivery (adjusted odds ratio [aOR]: 1.7 [1.1-2.8] and aOR: 5.9 [2.7-13.0], respectively). Individuals with GDM also demonstrated similar rates with BW% > 90% but not cesarean section(aOR: 3.9 [1.8-8.5] and aOR: 1.4 [0.9-2.1], respectively). The remaining maternal and fetal outcomes were similar. CONCLUSION: Women with impaired glucose tolerance should have a third-trimester ultrasound to identify an increased risk of perinatal complications. KEY POINTS: · Women with elevated blood glucose screening should be evaluated with third-trimester ultrasound to identify risks for perinatal morbidity.. · The third-trimester ultrasound identifies individuals at risk for cesarean section.. · Counseling should be completed with individuals with polyhydramnios or accelerated growth..

Comparison of the efficacy and morbidity of flexible ureterorenoscopy for lower pole stones compared with other renal locations.

BACKGROUND AND PURPOSE: Flexible ureterorenoscopy (f-URS) for lower pole stones (LPS) compared with other renal locations can be challenging because of anatomic and technical considerations. We aimed to compare the stone-free rate (SFR) and surgical complication rate with f-URS for LPS vs other renal locations. PATIENTS AND METHODS: We performed a retrospective, single-center study including 371 f-URS for renal stone retrieval performed in our institution between January 2004 and December 2010. Among the 371 procedures included in this analysis, 139 were performed for stones located in a single renal location other than the lower pole (group 1), and 232 for at least one stone located in the lower pole (group 2). We compared the efficacy (SFR) and the morbidity of f-URS between the two groups. The success of the procedure was defined as a complete SFR 6 months after f-URS. RESULTS: Age, sex, history of urolithiasis, body mass index, and preoperative stent placement did not differ between the two groups. No differences in stone characteristics were observed between both groups except stone size under 10 mm that was significantly higher in group 2 (P=0.018). Technical aspects of the procedure did not differ between the groups, except for more frequent use of an access sheath in group 2 (P=0.007). SFR was comparable between groups (P=0.774). The complication rate was similar in both groups, as was the severity of complications. By multivariate analysis, stone size >10 mm (P<0.0001) and multiple stone locations (P=0.001) were associated with f-URS failure, but lower pole location did not impact on SFR. CONCLUSION: In our study, stone location, in particular LPS, did not have any impact on efficacy and morbidity of f-URS. Only multiple locations and stone size >10 mm seemed to significantly decrease the SFR, without impacting morbidity.

Renal cell carcinoma (RCC) in patients with end-stage renal disease exhibits many favourable clinical, pathologic, and outcome features compared with RCC in the general population.

BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE: Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS: Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION: All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS: Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS: The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS: RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.