Pregnancy and development of diabetes in First Nations and non-First Nations women in Alberta, Canada.

AIM: To conduct a retrospective population-based study to examine the risk of developing diabetes after delivery in First Nations and non-First Nations women in Alberta. METHODS: Delivery records (1999-2014) were linked to provincial administrative data, which allowed for a maximum follow-up of 16 years after delivery. Prevalence of pregnancy risk factors were compared by First Nations status. Hazard ratios for diabetes after delivery by First Nations status, high pre-pregnancy body weight (≥91 kg) and gestational diabetes status were estimated using the Cox proportional hazards model. RESULTS: Age-adjusted prevalence of gestational diabetes (7.9% vs 4.6%; P<0.0001), high pre-pregnancy body weight (18.8% vs 10.2%; P<0.0001) and diabetes after delivery (3.9% vs 1.1%; P<0.0001) were higher in First Nations women than in non-First Nations women. Development of diabetes after delivery was higher with First Nations status (hazard ratio 3.0, 95% CI 2.6-3.4), high pre-pregnancy body weight (hazard ratio 3.6, 95% CI 3.3-4.0) and gestational diabetes status (hazard ratio 19.2, 95% CI 17.9-20.6). The highest risk was within First Nations women with high pre-pregnancy body weight and gestational diabetes (hazard ratio 54.8, 95% CI 45.2-66.5) compared to women without these three risk factors. Reduced prenatal visits per pregnancy (8.4 vs 10.7; P<0.0001) and delayed first prenatal visit (time to delivery 23.7 vs 26.7 weeks; P<0.0001) were observed in First Nations women compared to non-First Nations women. CONCLUSION: First Nations women are at greater risk of developing diabetes after pregnancy, with gestational diabetes being the strongest predictor. Strategies that target the specific needs of First Nations women before, during and after pregnancy are required.

Factitious diabetes mellitus and spontaneous hypoglycemia. Consequences of unrecognized Munchausen syndrome by proxy.

OBJECTIVE: To increase health-care professionals' awareness and knowledge of factitious illness by proxy, or Munchausen syndrome by proxy, in relatives of diabetic patients. RESEARCH DESIGN AND METHODS: A case report is described of a 14-yr-old male who has a 6-yr history of diet-controlled diabetes mellitus, and a 6-mo history of reported spontaneous hypoglycemia. RESULTS: Neither diabetes nor spontaneous hypoglycemia was present in this child on objective testing. The child was subjected to inappropriate use of a strict diabetic diet and daily glucometer measurements for at least 8 yr. The father had convinced his son and health-care professionals of these diagnoses, in spite of evidence of the contrary. CONCLUSIONS: When confronted with history and clinical findings that contradict laboratory findings, health-care professionals should have a high index of suspicion for factitious illness and should pursue it aggressively with the help of legal services.

High incidence of IDDM over 6 years in Edmonton, Alberta, Canada.

OBJECTIVE: To determine the incidence of IDDM among children 0-14 years of age in Edmonton, Alberta, between 1990 and 1995 by means of a population-based registry. RESEARCH DESIGN AND METHODS: Children < 15 years of age diagnosed with IDDM between January 1990 and December 1995 were registered according to criteria of the World Health Organization (WHO) Multinational Project for Childhood Diabetes. The primary source of case ascertainment consisted of office records of pediatricians and endocrinologists. The secondary source consisted of inpatient records from the main city hospitals. RESULTS: Between 1990 and 1995, 211 IDDM patients < 15 years of age were detected by the two sources. All but 15 of them were of European ancestry. The ascertainment-corrected incidence rates of this ethnic group (constituting 77% of the population) for the 6 years were 38.6, 23.5, 23.3, 24.2, 22.0, and 24.3 per 100,000, respectively, with case ascertainment rates of 75-95%. The age-adjusted rate over the 6-year period was 25.7 per 100,000 with a case ascertainment rate of 84.3%. No sex difference was observed. The highest incidence occurred in the 10- to 14-year-old age-group, and more cases were detected between January and March than at other periods in the year. CONCLUSIONS: The incidence of IDDM among the European-derived population in Edmonton between 1990 and 1995 is the highest rate over a 6-year period to be reported in North America, comparable to that in Prince Edward Island, Canada, and to the highest rates in the world.

Insulin action does not change during the menstrual cycle in normal women.

Normal women have alterations in carbohydrate metabolism during pregnancy and when taking oral contraceptives, and clinical observations suggest that diabetic women need more insulin during menstruation. We, therefore, studied insulin action in normal women during the menstrual cycle in the follicular, luteal, and menstrual phases. Glucose tolerance was similar at all three times. Specific insulin receptor binding to monocytes did not change during the menstrual cycle. Euglycemic insulin clamp studies at four different insulin infusion rates (15, 40, 120, and 240 mU/M2 X min) showed no differences in insulin sensitivity or responsiveness throughout the menstrual cycle, and hepatic glucose output did not change. These studies suggest that if insulin action is impaired during menstruation in diabetic women it is because of factors that are not detected in normal women.

Age-related decline in interleukin 2 production in response to influenza vaccine.

Articles in the recent literature document an abnormal antibody response in elderly persons to influenza vaccination. Several studies have presented evidence to show that immune dysfunction in aged mice and humans may be due to a defect in the production of interleukin 2 (IL2) by helper T cells (TH). Cultures of peripheral blood mononuclear cells (PBMC) were prepared from blood samples taken at eight weeks after vaccination (0.5 mL of Armand-Frappier, 15 micrograms/0.5 mL each of A/Taiwan/1/86, A/Leningrad/360/86, and B/Ann Arbor/1/86 administered in the fall of 1987) from a group of elderly men and a young control group. Peripheral blood mononuclear cells were frozen in 10% dimethyl sulfoxide (DMSO) until all the cells were cultured. After stimulation with a 1/320 dilution of the same influenza vaccine, cultures of PBMC from young controls showed a significantly greater increase in IL2 production than the cultures of PBMC from the elderly group of patients. This was statistically significant at both day 3 (P less than .01) and day 5 (P less than .05) of culture using the Mann-Whitney U test. Previous experiments that have shown defective IL2 production related to aging have used potent mitogens such as concanavalin A and phytohemagglutinin to stimulate TH. This study provides evidence that defective IL2 production may also occur in response to physiologic antigenic stimulation and may be one explanation for the reduced efficacy of influenza vaccination in elderly persons.

Lack of metabolic effects of a triphasic formulation containing norethindrone in normal women studied prospectively.

The glucose and insulin responses to oral glucose tolerance tests and lipid values in normal women taking a triphasic pill containing norethindrone (Ortho 7/7/7) were performed. After three months, no significant changes in these metabolic indices were found. These results confirm and expand the knowledge regarding the metabolic safety of norethindrone-containing triphasic formulations.

PIP: Glucose and insulin responses to oral glucose tolerance tests and serum lipid values were studied in a prospective review of users of Ortho 7/7/7, a triphasic oral contraceptive (OC) containing ethinyl estradiol and norethindrone. Study subjects included 7 healthy college students in whom the metabolic parameters were measured at baseline and after 3 months of Ortho 7/7/7 use. No significant differences between these 2 time points were measured in terms of either responses to the glucose tolerance test or lipid determinations. The only other study to examine carbohydrate metabolism in users of a norethindrone-containing triphasic OC also found no changes in either glucose, insulin, or lipid levels. These findings tend to confirm the theory that triphasic OCs have lessened metabolic effects. However, it should be kept in mind that profound changes in metabolic parameters might not have been detected in this study given the small number of subjects and the short follow-up period. Of particular interest would be an assessment of the use of norethindrone-containing formulations in women with a history of carbohydrate intolerance.

Primary hypothyroidism presenting as growth delay and pituitary enlargement.

We report the case of a young boy being considered for pituitary surgery because of pituitary enlargement found during assessment of growth delay. There was no goitre but he was hypothyroid clinically and biochemically. The finding of an elevated TSH suggested primary thyroid disease with thyrotroph hyperplasia. Treatment with L-thyroxine resulted in prompt resolution of his pituitary enlargement and improvement in his visual fields.

Cardiopulmonary resuscitation and older adults' expectations.

The purpose of this study was to determine the knowledge, attitudes, and opinions of older adults about cardiopulmonary resuscitation (CPR). Sixty hospitalized/institutionalized older adults were interviewed. Most had little or no accurate knowledge of CPR. However, many stated that they would wish to receive CPR and would want to be involved in the CPR decision-making process. The knowledge deficits and misconceptions of older adults should be addressed in order that they may become informed and active participants in the CPR decision-making process.

Coexistence of Munchausen's syndrome and multiple personality disorder: detailed report of a case and theoretical discussion.

Patients with factitious disorders represent an important challenge to medical and psychiatric caregivers. The literature on Munchausen's syndrome abounds with entertaining descriptions of these flamboyant patients, but rarely is there significant understanding of the mechanisms of the disease. We present a case where Munchausen's syndrome coincided with multiple personality disorder (MPD). The patient has been known to us for over 10 years, and some resolution of the Munchausen's syndrome is occurring in response to appropriate therapy for the multiple personality disorder. We point out the need to seek out dissociative phenomena in self-abusive patients, as this may provide a clue for psychodynamic understanding and rational therapy.

Effectiveness of a group psychoeducation program for the treatment of subclinical disordered eating in women with type 1 diabetes.

The coexistence of type 1 diabetes mellitus and disordered eating is associated with poor metabolic control, poor adherence to diabetes treatment regimens, and increased risk of long-term diabetic complications. This study assessed whether a six-session group psychoeducation program would improve metabolic control, diabetes treatment adherence, eating disorder symptomatology, and general psychopathology in women with coexisting type 1 diabetes and subclinical disordered eating. Fourteen women were assigned to the treatment group (n=8) or wait-list control group (n=6). Measurements were taken at baseline, post-intervention, and one month post-intervention. There were no significant differences in how the treatment group and wait-list control group changed over time. Between the first and second measurements, both groups demonstrated significant improvements in depression and general emotional distress. The results suggest that a six-session group psychoeducation program is no more effective than a wait-list control group for treating subclinical disordered eating in women with type 1 diabetes. Further research is required to determine the most effective treatment for this population.

Birth weight predicts both proteinuria and overweight/obesity in a rural population of Aboriginal and non-Aboriginal Canadians.

The risk for many chronic diseases appears to be mediated in part by birth weight. Among Aboriginal Canadians, the prevalence of end-stage renal disease and cardiovascular disease risk is disproportionately high, largely because of elevated diabetes prevalence. The relationships between birth weight (and other potential risk factors) and diabetes, hypertension, proteinuria and overweight/obesity were explored in 1439 rural Albertans (Canada), of whom 67.3% were Aboriginal. At voluntary outreach screening programs, demographic and clinical data were measured and recalled birth weights recorded. Statistical modeling using logistic regression was used to evaluate the relationships. In the final adjusted models, associations remained for low birth weight and proteinuria [odds ratio (OR) 2.36; 95% CI 1.24-4.49], as well as for high birth weight and overweight/obesity (OR 1.58; 95% CI 1.00-2.53). These findings emphasize the need to strive for healthy pregnancies, with appropriate weight gains in these and other disadvantaged populations around the world.

Self-monitoring in Type 2 diabetes: a randomized trial of reimbursement policy.

AIM: Self-monitoring of blood glucose is often considered a cornerstone of self-care for patients with diabetes. We assessed whether provision of free testing strips would improve glycaemic control in non-insulin-treated Type 2 diabetic patients. METHODS: Adults with Type 2 diabetes, excluding those with private insurance or using insulin, were recruited through community pharmacies and randomized to receive free testing strips for 6 months or not; all patients received similar baseline education and a glucose meter. Primary outcome was change in HbA(1c) over 6 months. RESULTS: We randomized 262 patients (131 intervention and 131 control subjects). Mean age was 68.4 years (sd 10.9), 48% were male, mean duration of diabetes was 8.2 years (sd 7.2), 97% used oral glucose-lowering agents and mean baseline HbA(1c) was 7.4% (sd 1.2). After 6 months, we observed no difference in HbA(1c) between intervention and control patients, after adjusting for baseline HbA(1c)[adjusted difference 0.03, 95% confidence interval (CI) -0.16, 0.22; P = 0.78]. A per protocol analysis of study completers (152/262; 60%) yielded similar results. Intervention patients reported testing 0.64 days per week more often than control subjects (95% CI 0.18, 1.10; P = 0.007), although testing was not associated with better glycaemic control (Pearson r = -0.10, P = 0.12). CONCLUSIONS: Reducing financial barriers by providing free testing strips did not improve glycaemic control in patients with Type 2 diabetes not using insulin. Our results question the value of policies that reduce financial barriers to testing supplies in this population.

Reduced cardiovascular morbidity and mortality associated with metformin use in subjects with Type 2 diabetes.

AIM: Metformin therapy reduces microvascular complications in Type 2 diabetes; questions remain, however, regarding its impact on macrovascular events. This study examined metformin use in relation to risk of cardiovascular-related hospitalization and mortality. METHODS: We conducted a retrospective cohort analysis, using Saskatchewan Health administrative databases to identify new users of oral antidiabetic drugs. Subject groups were defined by medication use during 1991-1999: sulphonylurea monotherapy, metformin monotherapy, or combination therapy. Deaths and non-fatal hospitalizations recorded during the study period were identified as cardiovascular-related from ICD-9 codes. The main outcome was a composite of first non-fatal hospitalization or death. Standard multivariate techniques, including propensity scores, were used to adjust for potential confounding. Multivariate Cox proportional hazard models were used to examine the relationship between metformin use and the composite endpoint. RESULTS: Metformin monotherapy was associated with a lower risk of the composite endpoint (adjusted hazard ratio 0.81; 95% confidence interval 0.68, 0.97) compared with sulphonylurea monotherapy. Combination therapy with meformin and a sulphonylurea was associated with lower mortality, but had similar hospitalization rates, to sulphonylurea monotherapy. CONCLUSIONS: Metformin monotherapy was associated with a lower risk of cardiovascular-related morbidity and mortality, and combination metformin and sulphonylurea therapy was associated with a reduced risk of fatal cardiovascular events, when compared with sulphonylurea monotherapy.

'Spontaneous'/uremic hypoglycemia is not a distinct entity: substantiation from a literature review.

A review of the literature on 'spontaneous'/uremic hypoglycemia reveals that in only 4 of 36 cases is there no clear explanation for the low blood glucose. In all other cases there were factors in addition to chronic renal failure that could have accounted for hypoglycemia. These factors included states of malnutrition, drugs, and other illnesses. We propose that there is no merit in the term 'spontaneous' hypoglycemia, and that the multifactorial nature of uremic hypoglycemia should be appreciated.

Description of a diabetes support group: lessons for diabetes caregivers.

A weekly psychotherapy group has been established with 21 diabetic patients (mean sessions attended per patient 12.0 +/- 8.9). In this non-structured group, the topics spontaneously chosen most often for discussion included complications and fears regarding complications, diet, and relationships with physicians. Other topics included difficulties achieving diabetes control, relationships with families, devices for day to day management, pregnancy and parenting, depression and eating disorders, and occupational concerns including driving and diabetes. The presence of a physician co-therapist was found to be valuable. Examples are provided of the patients' concerns. It is felt that understanding patients' needs for information and communication with physicians and allied health professionals will enrich the caregiver-patient relationship.