Danish Diabetes Birth Registry 2: a study protocol of a national prospective cohort study to monitor outcomes of pregnancies of women with pre-existing diabetes.

INTRODUCTION: Despite technological developments and intensified care, pregnancies in women with pre-existing diabetes are still considered high-risk pregnancies. The rate of adverse outcomes in pregnancies affected by diabetes in Denmark is currently unknown, and there is a limited understanding of mechanisms contributing to this elevated risk. To address these gaps, the Danish Diabetes Birth Registry 2 (DDBR2) was established. The aims of this registry are to evaluate maternal and fetal-neonatal outcomes based on 5 years cohort data, and to identify pathophysiology and risk factors associated with short-term and long-term outcomes of pregnancies in women with pre-existing diabetes. METHODS AND ANALYSIS: The DDBR2 registry is a nationwide 5-year prospective cohort with an inclusion period from February 2023 to February 2028 of pregnancies in women with all types of pre-existing diabetes and includes registry, clinical and questionnaire data and biological samples of mother-partner-child trios. Eligible families (parents age ≥18 years and sufficient proficiency in Danish or English) can participate by either (1) basic level data obtained from medical records (mother and child) and questionnaires (partner) or (2) basic level data and additional data which includes questionnaires (mother and partner) and blood samples (all). The primary maternal outcome is Hemoglobin A1c (HbA1c) levels at the end of pregnancy and the primary offspring endpoint is the birth weight SD score. The DDBR2 registry will be complemented by genetic, epigenetic and metabolomic data as well as a biobank for future research, and the cohort will be followed through data from national databases to illuminate possible mechanisms that link maternal diabetes and other parental factors to a possible increased risk of adverse long-term child outcomes. ETHICS AND DISSEMINATION: Approval from the Ethical Committee is obtained (S-20220039). Findings will be sought published in international scientific journals and shared among the participating hospitals and policymakers. TRIAL REGISTRATION NUMBER: NCT05678543.

Percutaneous flexor tenotomy for preventing and treating toe ulcers in people with diabetes mellitus.

INTRODUCTION: The purpose was to examine the effectiveness of flexor tenotomy in a modified technique to prevent and heal neuropathic and neuroischaemic pressure ulcers on the tip of the toe in claw- or hammer-toe deformities in people with diabetes. PATIENTS AND METHODS: A consequetive 4 years series of 38 patients was retrospectively studied. Percutaneous tenotomy on the superficial and deep flexor tendons was performed in 65 toes through a small transverse plantar stab incision just proximal to the web level. There were 16 (42%) patients with 27 ulcerated toes and 22 (58%) patients with 38 toes with impending ulceration. Ten patients had neuropathic ulcers and six patients had neuro-ischaemic ulcers. Sixteen patients (42%) had macrovascular disease. Ten (26%) had proliferative rethinopathy, 7 (18%) macroalbuminuria and 18 (47%) microalbuminuria. RESULTS: All surgical incisions healed uneventfully. Twenty-five (93%) of the toe ulcers healed in median 21 days (range 7-224 days). Three patients had recurrence of the ulcer. There were no infections in the incisions or toe amputations. No patients treated with preventive tenotomy experienced toe ulceration. No complications were recorded in neuro-ischaemic ulcers. During the follow up period of median 31 months (range 2-48 months) 33 other ulcers were recorded in 18 patients (47%). One of these developed a transfer ulceration under the adjacent metatarso-phalangeal joint and another had a late pressure ulcer on a neighbouring toe. The other 31 ulcers were not related to ulcers treated with tenotomy. CONCLUSION: Tenotomy is a simple, safe and effective procedure for preventing and treating distal plantar neuropathic toe ulcers in claw toe or hammer toe deformities in people with diabetes with or without serious co-morbidity. The results suggest that tenotomy should be considered also in neuroischaemic ulcers.

Surrendering to the Process: Innovation in Developing CPD for General Practice.

In CME/CPD, a significant part of research is about effectiveness. Attention to the development process can be vital to understand how it impacts progress and results. This study aims to explore an innovative process of applying a combined approach using design-based research, collaborative innovation, and program theory to develop CPD about type 2 diabetes for GPs and clinic nurses with a group of interprofessional stakeholders. In particular, the development process of the combined approach and how it impacts the progress and the activities. We applied two qualitative methods. First, we analysed 159 documents from the development process, and second, eight semi-structured key informant interviews. Data were deductively analysed using 15 predefined elements derived from the combined approach combined with open coding analyses. The analysis showed how the combined approach structured the process. And the interviews broadened our understanding of the relationship between the process and the activities. Four additional themes were constructed from the open coding, including surrender to the process. Surrendering was a central part of the interviewees' participation in the process. The combined approach facilitated this unfamiliar experience of surrender. By supporting participants to surrender, the combined approach enabled an expansion of interprofessional collaboration and the development of innovative activities and learning methods in CPD on type 2 diabetes.

Quality of diabetes treatment in four orthopaedic departments in the Capital Region of Denmark.

INTRODUCTION: Hyperglycaemia during hospitalisation is associated with a longer and more complicated admission and with increased mortality. Therefore, guidelines suggest that blood glucose should be less than 10 mmol/l. In this audit, we aimed to describe the prevalence of diabetes patients at four orthopaedic departments in the Capital Region of Denmark and to measure the quality of in-hospital diabetes management. METHODS: We conducted audits of medical records in the electronic health record system for two months in 2019. All patients admitted were included in the audit. We gathered information on diabetes status, orthopaedic diagnosis, glycosylated haemoglobin and diabetes management. RESULTS: Among 2,463 included patients, 10% had diabetes. The three most frequent diagnosis groups were infection, fracture of lower extremity and hospitalised for alloplastic surgery. The number of blood glucose measurements during 24-hour perioperative care was 6.5. Among patients analysed, 10-20% did not have their blood glucose measured in the days following surgery. Among patients, 64% received insulin 1-50% of the required times. CONCLUSION: We demonstrated that 10% of hospitalised patients suffer from diabetes. The audit also showed that blood glucose is generally measured according to guidelines, whereas the treatment of an elevated blood glucose is far from being given according to guidelines. This may potentially delay recovery and prolong hospitalisation. FUNDING: none. TRIAL REGISTRATION: not relevant.

Variations in the Delivery of Primary Diabetes Care in Malaysia: Lessons to Be Learnt and Potential for Improvement.

BACKGROUND: The article describes variations in the organization of clinical services for diabetes patients in 10 public primary health clinics in Malaysia with the view to learn from current innovations and improve diabetes service provision. METHODS: This study combined the use of secondary data and a qualitative multicase study approach applying observations in 10 randomly selected Ministry of Health (MOH) health clinics in Kuala Lumpur and Selangor and semistructured interviews of the family medicine specialists from the same clinics. RESULTS: Although there are specific MOH guidelines for diabetes care, some clinics had introduced innovations for diabetes care such as the novel 'personalized care', 'one-stop-centre' and utilization of patients' waiting time for health education. Analysis showed that there was room for improvement in terms of task shifting to free precious time of staff with specialized functions, streamlining appointments for various examinations, increasing continuity of consultations with same doctors, and monitoring of performance. CONCLUSION: We contend that there is a potential for increased effectiveness and efficiency of primary diabetes care in Malaysia without increasing the resources - a potential that may be tapped into by systematic learning from ongoing innovation.

Impact of continuing medical education for primary healthcare providers in Malaysia on diabetes knowledge, attitudes, skills and clinical practices.

Background: Continuing Medical Education (CME) is a cornerstone of improving competencies and ensuring high-quality patient care by nurses and physicians. The Ministry of Health (MOH) Malaysia collaborated with Steno Diabetes Centre to improve diabetes-related competencies of general physicians and nurses working in primary care through a six-month training programme called the Steno REACH Certificate Course in Clinical Diabetes Care (SRCC).Objective: This impact evaluation aimed to assess the effect of participation of general physicians and nurses in the SRCC in selected public primary healthcare clinics in Kuala Lumpur and Selangor, Malaysia.Design: The quasi-experimental, embedded, mixed-methods study used concurrent data collection and the Solomon four-group design. Participants in an intervention group (Arm 1) and control group (Arm 3) were assessed by pre-and post-test, and participants in separate intervention (Arm 2) and control (Arm 4) groups were assessed by post-test only. Quantitative and qualitative methods were used to assess the effect of the programme.Results: Thirty-four of the 39 participants in the intervention groups (Arms 1 and 2) completed the SRCC and were included in the analysis. All 35 participants in the control groups (Arms 3 and 4) remained at the end of the study period. Significant improvements in diabetes-related knowledge, skills and clinical practise were found among general physicians and nurses in the intervention group after the six-month SRCC, after controlling the pretest effects. No clear changes could be traced regarding attitudes.Conclusion: SRCC participants had significant improvements in knowledge, skills and clinical practice that meet the current needs of general physicians and nurses working in primary care in Malaysia. Thus, SRCC is an effective CME approach to improving clinical diabetes care that can be scaled up to the rest of the country and, with some modification, beyond Malaysia.

Diabetes care may be improved with Steno Quality Assurance Tool--a self-assessment tool in diabetes management.

UNLABELLED: To evaluate if improvements in the quality of diabetes care in Indian clinics can be obtained by simple self-surveillance PC-based software. METHOD: Nineteen Indian diabetes clinics were introduced to the principles of quality assurance (QA), and to a software program, the Steno Quality Assurance Tool (SQAT). Data was entered for an initial 3 months period. Subsequently data were analyzed by the users, who designed plans to improve indicator status and set goals for the upcoming period. A second data entry period followed after 7-9 months. RESULTS: QA data was analyzed from 4487 T2DM patients (baseline) and 4440 (follow-up). The average examination frequency per clinic of the following indicators increased significantly: lipid examination (72-87%) (p=0.007), foot examination (80-94%) (p=0.02), HbA1c investigation (59-77%) (p=0.006), and urine albumin excretion investigation (72-87%) (p=0.006). Outcome parameters also improved significantly: mean (SD) fasting and post prandial BG reduced from 144(16) to 132(16)mg/dl (p=0.02) and 212(24)-195(29)mg/dl (p=0.03), respectively. Systolic BP reduced from 139(6) to 133(4) (p=0.0008)mmHg and diastolic BP from 83(3) to 81(3)mmHg (p=0.002). CONCLUSION: Quality of diabetes care can be improved by applying SQAT, a QA self-surveillance software that enables documentation of changes in process and outcome indicators.