Managing type I diabetes in pregnancy: how near normal is necessary?

OBJECTIVE: This was a feasibility study to determine if pregnant women with type I diabetes managed with liberal target glucose values will have a decreased frequency of hypoglycemia with no differences in adverse outcomes compared with tightly controlled subjects. STUDY DESIGN: Twenty-two women who had type I diabetes were randomized in first trimester to 'rigid' and 'less rigid' groups. Participants recorded blood glucose results and symptoms of hypoglycemia on memory-based meters. RESULTS: Mean maternal glucose was significantly greater in first and second trimesters among patients in the 'less rigid' group. Both subjective and objective hypoglycemias were more frequent in the 'rigid' group. There were no differences between groups in cesarean deliveries, birth weights and neonatal glucose concentrations. CONCLUSIONS: Utilizing glucose targets higher than those conventionally recommended in pregnancies of women who have type I diabetes may decrease maternal hypoglycemia while not increasing maternal or perinatal morbidity. The findings of this study justify further investigation with a larger patient base.

Spontaneous regression of restenosis: an angiographic study.

OBJECTIVES: This study was designed to examine the possibility that spontaneous regression in stenosis severity occurs over time in patients with restenosis after percutaneous transluminal coronary angioplasty. BACKGROUND: The underlying mechanisms of restenosis are intimal hyperplasia and smooth muscle cell proliferation in response to vascular injury. We hypothesized that the initial hyperplastic response is followed by dynamic remodeling and eventual spontaneous regression, leading to stabilization or a reduction in stenosis severity. METHODS: A total of 136 patients participated in a trial to evaluate the efficacy of fish oil versus placebo in preventing restenosis after angioplasty. One hundred thirteen patients completed this study with angiographic follow-up, of whom 56 had restenosis. Of these, 19 were asymptomatic and did not undergo repeat revascularization; 15 consented in a separate study to undergo repeat angiography, which was performed 6 to 25 months later to assess the possibility of regression. RESULTS: There was a significant mean (+/- SD) decrease in lesion severity from 66.9 +/- 8.7% to 47.5 +/- 9.0% (p < 0.0001) and a significant mean increase in minimal lumen diameter from 0.91 +/- 0.31 mm to 1.44 +/- 0.35 mm (p < 0.0001). No patient showed progression of stenosis, but regression of restenosis, defined as a decrease in minimal lumen diameter > or = 0.2 mm, was noted in 12 of the patients. CONCLUSIONS: Although all 15 study patients were asymptomatic, similar changes may occur in symptomatic patients. A trial of medical therapy may be appropriate in asymptomatic or mildly symptomatic patients before further interventions. This strategy would avoid unnecessary invasive procedures, prevent a "restenosis cycle" and result in significant cost savings.

Predictors of perceived health in hospitalized older persons: a cross-sectional and longitudinal study.

OBJECTIVES: To identify the predictors of perceived health and predictors of changes in perceived health in frail hospitalized older persons during the year after hospitalization. DESIGN: Both cross-sectional and longitudinal multivariate analysis of data from a cohort followed for 1 year. SETTING: Six hospital in a group practice model health maintenance organization (HMO) in Southern California. PARTICIPANTS: A total of 1889 persons aged 65 or older who met at least one of 13 inclusionary criteria for a randomized trial of Comprehensive Geriatric Assessment consultation at admission and completed three Functional and Health Status Questionnaires (FHSQ) during a 12-month period. MEASUREMENTS: Functional and health status measures included basic and intermediate activities of daily living (BADL and IADI) and social activities (SA) scales from the Functional Status Questionnaire as well as the mental health index (MHI) and current health perception (CHP), scales from the Medical Outcomes Study short from. Subject's severity of disease was measured by the Resource Demand Scale (RD Scale). RESULTS: In the cross-sectional analyses, MHI score, IADL score, RD Scale, history of falls during the 3 months before hospitalization, and female gender were significant predictors of perceived health in all models for each time point, BADL score, age, presence of incontinence, and ethnicity were significant in the model for baseline only, and SA score was significant in models for 3 months and 12 months only. In the longitudinal analyses, the baseline CHP score and the changes in MHI, IADL, and BADL score predicted CHP change from 0 to 3 months and from 3 to 12 months. CONCLUSIONS: Functional and psychosocial health indicators are the most important and most consistent predictors of perceived health. Our study showed that several predictors of perceived health in cross-sectional analysis did not predict changes in perceived health over a 1-year period. Hence, to fully understand the medical and social contributors to perceived health, a comprehensive approach using both cross-sectional and longitudinal analyses is necessary.

Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies.

OBJECTIVE: To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations. DESIGN: Validation study. SETTING: A health maintenance organization and a geriatrics academic program. PARTICIPANTS: A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms. MEASUREMENTS: Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker. RESULTS: On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83. CONCLUSION: A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.

The use of targeting criteria in hospitalized HMO patients: results from the demonstration phase of the Hospitalized Older Persons Evaluation (HOPE) Study.

OBJECTIVE: To determine the yield of standardized targeting criteria for identifying hospitalized HMO patients who are at high risk for mortality and nursing home placement and, therefore, may be appropriate for comprehensive geriatric assessment. DESIGN: Prospective cohort study. SETTING: Four HMO (Southern California Kaiser-Permanente) hospitals. SUBJECTS: 3,697 patients 65 years of age or older admitted to any inpatient service from July 1 through September 30, 1990. MAIN OUTCOME MEASURES: Screening measures for standardized targeting criteria, administered 24-48 hours after admission. RESULTS: Overall, 35.1% of patients screened met at least one inclusionary criterion, which is considerably higher than other published reports. The most commonly met criteria were incontinence, impairment in performing activities of daily living, malnutrition, and immobility. The percentage of patients meeting at least one criterion and meeting each criterion varied considerably among hospitals. The vast majority of patients (83%) who were judged appropriate for assessment met at least three criteria. CONCLUSIONS: The yield of standardized criteria differs when applied to patients in different health care systems and to patients at different hospitals within a health care system, which may reflect differences in the populations being served and the practice styles of physicians and the delivery system. Because no single criterion identified more than approximately half of patients who were judged appropriate for assessment, it is likely that a battery of criteria will be necessary to identify these patients.

Rationale and design of a multi-center randomized trial of comprehensive geriatric assessment consultation for hospitalized patients in an HMO.

OBJECTIVE: To describe the evaluation of an interdisciplinary comprehensive geriatric assessment (CGA) consultation program for targeted hospitalized patients. DESIGN: Multi-center randomized clinical trial (RCT) at four hospitals where patients were randomly assigned to CGA consultation or usual care by the attending physician, and a non-equivalent control group (NCG) at two hospitals. SETTING: Six hospitals in a multi-specialty group practice model health maintenance organization (HMO). PARTICIPANTS: 3593 patients age 65 years or older meeting at least one of 13 inclusionary criteria at admission. INTERVENTION: Screening by hospital staff and standardized CGA consultation conducted by a nurse practitioner, social worker, and geriatrician at the four RCT hospitals. MAIN OUTCOME MEASURES: Functional and health status, mortality, rehospitalization, and cost-effectiveness of the CGA program at 1 year post-randomization; validation of targeting (inclusionary) criteria that identify subgroups of patients deriving benefit from CGA; and physician contamination (learning from CGA and changing treatment provided to control patients). CONCLUSIONS: A number of methodological issues need to be considered when conducting effectiveness trials of CGA. The concurrent design of a multi-center RCT, coupled with the NCG to determine physician contamination, is an innovative approach intended to determine more precisely the cost-effectiveness of CGA for frail hospitalized elderly persons. The large and heterogeneous patient population and the broad array of inclusionary criteria will permit the evaluation of the benefit of CGA for subgroups. All these features are intended to enhance the generalizability of study results.

Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study.

OBJECTIVE: To report a prospective multicenter comparison of outcomes of patients who attempted trial of labor and those who underwent elective repeat cesarean. METHODS: During the study interval, all pregnant women with previous cesarean delivery cared for at Kaiser Permanente Hospitals in Southern California were studied regardless of whether trial of labor or elective repeat cesarean was planned. RESULTS: Of 7229 study patients, 5022 (70%) had a trial of labor and 2207 had elective repeat cesarean operations. Seventy-five percent (3746) of those opting for trial of labor went on to deliver vaginally. The rate of uterine rupture was less than 1% and there were no maternal deaths related to uterine rupture. The hospital length of stay, incidence of postpartum transfusion, and incidence of postpartum fever were all significantly higher in the elective repeat cesarean group than in the trial of labor group. CONCLUSIONS: Labor after previous cesarean delivery has a 75% success rate, with a risk of uterine rupture of less than 1%. Neither repeat cesarean delivery nor trial of labor is risk-free. With careful supervision, trial of labor eliminates the need for a large proportion of repeat cesarean operations.

Low-grade Papanicolaou smears and the Bethesda system: a prospective cytohistopathologic analysis.

OBJECTIVE: To examine the clinical usefulness of the Bethesda classification system of low-grade cervicovaginal cytology as it relates to predicting underlying histology and aiding in triage to colposcopy. METHODS: We evaluated 1454 women with abnormal cytologic screening results: 782 with atypical squamous cells of uncertain significance (atypia), 355 with low-grade squamous intraepithelial lesions (SIL) determined by the presence of human papillomavirus (HPV) alone, and 317 with low-grade SIL determined by the presence of cytologic evidence of mild dysplasia (cervical intraepithelial neoplasia [CIN] I) devoid of HPV cytopathologic features. All women underwent colposcopy, directed-punch biopsy or loop electrosurgical excision, and/or endocervical curettage (ECC), as indicated. RESULTS: Women from the low-grade SIL-CIN I referral cytology group were significantly more likely to harbor all grades of biopsy-proven dysplasia than were those from the atypical squamous cells of uncertain significance and low-grade SIL-HPV groups, which showed no statistical differences. CONCLUSIONS: Contrary to the Bethesda system, which combines CIN I and HPV changes because of cytomorphologic similarities, this study suggests that patients with HPV cytologic smears are similar to patients with atypical smears and are less likely to harbor any biopsy-proven CIN lesions than are patients with CIN I cervicovaginal smears. If excluded from colposcopic triage, approximately 5% of patients with atypical cytologic smears from a well-screened population similar to ours will harbor high-grade lesions that may progress during any waiting period. Triage of low-grade cervicovaginal smears based on histopathologic correlation is encouraged.

Immunocytotoxicity effects of polycyclic aromatic hydrocarbons on mouse lymphocytes.

The in vivo effects of 3 polycyclic aromatic hydrocarbons (PAH): 3-methylcholanthrene (MCA), benzo[a]pyrene (BaP) and benzo[e]pyrene (BeP) on the ability of mouse lymphocytes to bind and kill target tumor cells in vitro were measured. C57 and C3H inbred mice were preimmunized with P815 tumor cells and then treated with a single i.p. injection of corn oil alone or with varying doses of the above PAH compounds (0.5-50 mg/kg body wt). At different post-injection times, antigen sensitized splenic lymphocytes (SL) and peritoneal exudate lymphocytes (PEL) were measured for binding and killing rates, using a single cell assay. MCA doses of 5 and 50 mg/kg inhibited SL: target cell binding 29-42% and PEL: target cell binding 23-60%. BaP had a similar significant dose dependent suppression on SL and PEL binding. Target cell killing rates by SL and PEL from MCA and BaP treated C57 and C3H mice were consistently suppressed at significant levels, compared to oil injected controls (P less than 0.05). On the other hand, binding and killing rates by SL and PEL from BeP treated mice showed an inconsistent and borderline significance at the above dose levels. When measured as a function of post-injection time of MCA, binding rates of SL from both mouse strains remained essentially unchanged after 10, 30 and 45 days. Target cell killing by SL from C3H and C57 mice, however, was suppressed 55-65% after 10-30 days post-injection. At 45 days post-injection, the capacity of SL to kill target tumor cells was restored to 64-70% of control values. The results suggest that binding is an early event that depends on dose, whereas target cell killing is a function of dose and post-injection time.

The urban church and cancer control: a source of social influence in minority communities.

A study was conducted to examine the efficacy of a church-based model of social influence in improving access to and participation of underserved minority women in a cervical cancer control program. The model expanded on strategies used in previous hypertension control and health promotion research. A total of 24 churches, stratified by faith tradition, were randomly selected to participate in the cancer control program from a pool of 63 churches in a defined geographic area of Los Angeles County, CA. Female parishioners ages 21 years and older were eligible to participate in cervical cancer education sessions, and screening was offered to adult women who had not had Papanicolaou tests within the last 2 years. Church participation rate was 96 percent. Thirty lay health leaders were selected by the clergy to serve as messengers, recruiters, and organizers for their respective congregations. Ninety-seven percent of these lay health leaders participated in two training sessions designed to prepare them for their leadership role. Social support structures such as child care, meals, or transportation for targeted women were organized by lay health leaders in 78 percent of the churches. A total of 1,012 women between the ages of 21 and 89 years attended educational sessions. Forty-four percent of the eligible women were targeted for screening because they had not had a Papanicolaou test within the last 2 years or had never been screened. Black women were 6.6 times more likely than Hispanics to have been screened in the past 2 years. Hispanic women were 4.2 times more likely than African Americans never to have had a Papanicolaou test or been tested in 3 or more years.Overall, 90 percent of the women targeted for screening recruitment presented for tests.Fifty-two percent of the churches initiated cancer control activities by the end of the 2-year period following the culmination of the intervention program.The findings suggest that a church-based model of social influence can leverage the participation of minority women in cervical cancer control, provide access to underserved Hispanic women in particular,and sustain cancer control activities beyond the life of an intervention program.The findings further suggest that a more discrete assessment of screening history may improve the participation levels of African American women, and that the gratis offering of screening services may adversely affect their participation rates.

Alternative prenatal care. Impact of reduced visit frequency, focused visits and continuity of care.

OBJECTIVE: To investigate the impact of an alternative prenatal care program for low-risk patients. STUDY DESIGN: Five hundred forty-nine low-risk pregnant women were allocated to the study and control groups. The study group received, on average, eight visits, all of them with one of nine study providers. Each study visit had specific objectives and accompanying targeted patient education handouts. The control group received the usual prenatal care (on average, 13 visits) with different providers, according to the customary schedule. RESULTS: There were no significant pregnancy outcome differences between the groups. The study vs. control group differed significantly (P < .0001) in patient satisfaction regarding the number of prenatal visits. There was a higher level of satisfaction in the study group concerning continuity of care (P < .0001). The alternative prenatal care program reduced the number of prenatal visits by 27% and was not associated with any change in maternal or perinatal outcomes. Patient satisfaction parameters were either maintained or improved with alternative prenatal care. CONCLUSION: An alternative prenatal care program for low-risk patients reduced resource utilization without adversely affecting prenatal care process variables, pregnancy outcome or patient satisfaction.

Cancer rate differentials between blacks and whites of three metropolitan areas.

This article presents a comparison of the cancer incidence and mortality rates for the populations of the metropolitan areas of Los Angeles, Atlanta, and Nashville. The results reveal that cancer of the lung, prostate, breast, and cervix should be of major concern to all, but especially to blacks and residents of Nashville. The findings have specific implications for the prevention of cancer in the black population of the United States.

CD8+ lymphocyte counts and the risk of death in advanced HIV infection.

BACKGROUND: Mortality related to human immunodeficiency virus (HIV) infection occurs predominantly in patients with CD4+ lymphocyte counts of less than 50 cells/mm3. We followed 133 HIV-infected patients with enrollment CD4 counts of less than 50 cells/mm3 to determine if the risk of death during a 1-year period could be predicted by a single enrollment CD8+ lymphocyte count. METHODS: Enrollment data including age, sex, T-cell subset counts, p24 antigen status, antiretroviral use, and preexisting HIV-related illnesses were collected on a cohort of 133 consecutive patients with enrollment CD4 counts of less than 50 cells/mm3. The cohort was followed for 1 year, and survival data were analyzed in relation to enrollment variables. RESULTS: The mean enrollment CD8 count of those patients alive at 1 year was 600 cells/mm3, compared with a mean enrollment CD8 count of only 370 cells/mm3 in patients who had died prior to 1 year (P < .001). For every 100-cell decline in the enrollment CD8 count, the risk of death increased by 16% (95% confidence interval [CI], 5% to 22%), independent of other enrollment variables, including CD4 counts and p24 antigen status. A significant CD8 count warning level of 415 cells/mm3, irrespective of the presence of other enrollment variables, was associated with death within 1 year. The Kaplan-Meier estimated chance of death within 1 year was 54% (95% CI, 42% to 66%) for patients with CD8 counts of less than 415 cells/mm3 compared with only 25% (95% CI, 14% to 36%) for patients with CD8 counts greater than 415 cells/mm3. CONCLUSIONS: This study finds that a single CD8 count has important prognostic significance in patients with advanced HIV infection and suggests that potential therapies to enhance CD8 counts might be beneficial to patients with advanced HIV infection.

[Criteria of Rigiscan normalcy in aged men]. / Critères de normalité de Rigiscan chez l'homme âgé.

PURPOSE: To define the changes in penile tumescence and rigidity in normally potent older men before a nerve-sparing radical retropubic prostatectomy (NS-RRP) and to establish a base-line for investigating erectile dysfunction in that age group. MATERIAL AND METHODS: 75 patients used the Rigiscan for 2-3 nights before undergoing a NS-RRP procedure. Rigiscan data were analyzed visually using Kaneko & Bradley criteria, and by computerized analysis. The computerized data were compared to the patient self-evaluation of potency (questionnaire), patient's age (above and below 60 years old), peak cavernosal artery velocity measured by Duplex Doppler scanning, and to the visual analysis of the Rigiscan data. RESULTS: 55 of 75 men (73%) completed three sessions. 42 men had at least 2 normal sessions, and when compared to the 33 with abnormal visual tracings, only age was significantly characteristic (p < 0.05). Tip event rigidity (%) in < 60 year-old men was greater than in older men (p < 0.01). Nearly all men had erections lasting more than 2 minutes, while only 29 of 74 had 10 minutes erections with rigidity > 70%. The best correlation between visual and computerized analyses was noted in the group of 54 men who experienced > 70% rigidity for more than 2 minutes. CONCLUSION: This large prospective series of potent older men studied by Rigiscan and other subjective and objective parameters helps establishing normative data in the diagnosis of erectile dysfunction. An important observation is clearly the lack of correlation between the patient's questionnaire or the Doppler findings and the Rigiscan data.

Irritable bowel-type symptoms in HMO examinees. Prevalence, demographics, and clinical correlates.

A study of irritable bowel-type symptoms in 1264 health examinees using a self-administered questionnaire and psychological tests revealed they are common throughout adulthood. Of affected subjects 68% were female, and those with the more severe type (> or = 3 Manning criteria) were predominantly female (80%). Fewer Asians than other racial/ethnic groups had these symptoms. Nongastrointestinal symptoms, physician visits, incontinence, laxative use, a stress effect on bowel pattern and abdominal pain, abdominal surgery, hysterectomy, childhood abuse, use of mind-altering drugs, depression, and anxiety were correlated with irritable bowel-type symptoms. Regression analysis found some of the clinical correlates were independent markers for irritable bowel-type symptoms and that sexual abuse was related to nongastrointestinal symptoms and abdominal surgery independent of irritable bowel-type symptoms. More severe irritable bowel-type symptoms were especially associated with nongastrointestinal symptoms, stress effects, sexual abuse, use of sedatives and oral narcotics, and a past alcohol problem. There are important demographic and clinical correlates with irritable bowel-type symptoms.

Efficacy of functional electrical stimulation in treating genuine stress incontinence: a randomized clinical trial.

Our objective was to determine the efficacy of functional electrical stimulation as a stand-alone therapy for female stress incontinence. The study was conducted as a prospective, double-blind, randomized controlled trial using subjective and objective outcome criteria. Patients enrolled in this study had stress incontinence consistent with International Continence Society criteria. Patients with significant pelvic prolapse or detrusor instability were excluded. Patients underwent twice-daily treatment sessions for a total of 3 months. Results were analyzed for confounding variables between the treatment and control groups. Statistical analysis was performed utilizing Fisher's exact test and the paired t-test. Of the 54 patients enrolled in this study, 44 completed the program. The dropout rate was similar for both the treatment and control groups. There was no statistically significant difference between the treatment and control groups with regard to age, gravity, parity, previous antiincontinence surgery, menopausal status, or previous hysterectomy. Objective success for the treatment group was 15% and for the control group, 12.5% (NS). The subjective success for the treatment group was 25% and for the control group, 29% (NS). There was no relationship demonstrated between age, parity, previous surgery, hysterectomy, or menopausal status and the successful treatment of genuine stress incontinence with functional electrical stimulation. In this patient population, functional electrical stimulation was no more effective at improving or eliminating the symptoms of genuine stress incontinence than was the daily retention of the control probe.

Critical care transport: outcome evaluation after interfacility transfer and hospitalization.

STUDY OBJECTIVE: To test the hypothesis that interfacility transfer is not associated with increased mortality, duration of stay, or readmission within 7 days. METHODS: We matched 3,298 patients who were hospitalized for chest pain or related complaints in Kaiser Permanente medical centers after transfer from the emergency department of a nonplan hospital (transported patients) with 3,298 patients of the same gender and age (+/-5 years) and with the same principal diagnosis who were hospitalized within 6 months without transfer in the same Kaiser Permanente medical center (directly admitted patients). Patients were compared in terms of outcome measures: in-hospital deaths, continued care in another facility, readmission within 7 days, in-patient length of stay (LOS), and LOS in special care units. RESULTS: The adjusted odds ratios for in-hospital mortality and readmission within 7 days were 1.0 (95% confidence interval,.8 to 1.4) and.9 (95% confidence interval,.7 to 1.2), respectively. The adjusted mean difference in LOS was -.1 days (95% confidence interval, -.2 to.1). Transported and directly admitted cardiac patients were also compared for all examined outcome measures at each of 10 medical centers. At a few medical centers, we observed significant difference in LOS, special care LOS, and continued care in another facility. However, all these differences were small, and most were probably random errors. CONCLUSION: Conservative patient selection criteria, pretransfer stabilization, and the use of appropriate equipment and medical personnel have resulted in the interfacility transfer program's achieving its goal of transferring high-risk patients without adverse impact on clinical outcomes or resource use.

Should the same glucose values be targeted for type 1 as for type 2 diabetics in pregnancy?

OBJECTIVE: Our purpose was to determine whether the same maternal glycemic control is necessary to achieve similar perinatal outcomes for type 1 as for type 2 diabetics. STUDY DESIGN: The subjects were all women with pregestational diabetes mellitus delivered of live-born singletons. Glycemic control was achieved with diet and insulin. Self-monitoring of blood glucose was performed before meals and at bedtime. Target glucose values were 60 to 90 mg/dl fasting and 60 to 105 mg/dl at other times. RESULTS: Of 60,628 deliveries, 46 type 1 and 113 type 2 diabetic women met inclusion criteria. Respective differences were found between type 1 and type 2 diabetics in average daily glucose levels (112 mg/dl vs 97 mg/dl, p < 0.001), percent of values within target ranges (35% vs 57%, p < 0.001), and mean amplitude of glycemic excursion (48.1 mg/dl vs 24.9 mg/dl, p < 0.001). At least one daily glucose value was < 50 mg/dl during 19% of observation days for type 1 vs 2% of observation days for type 2 pregnancies (p < 0.001). There were no statistically significant differences between type 1 and type 2 diabetic pregnancies in neonatal macrosomia (30% vs 34%), proportion of cesarean deliveries during labor for arrest disorders (67% vs 69%), shoulder dystocia (2% vs 6%), and neonatal hypoglycemia (18% vs 26%). CONCLUSIONS: Less stringent maternal glycemic control may permit comparable maternal and neonatal outcomes for type 1 compared with type 2 diabetics. Higher target values for type 1 diabetics may decrease the frequency of maternal hypoglycemic episodes.

When is fasting really fasting? The influence of time of day, interval after a meal, and maternal body mass on maternal glycemia in gestational diabetes.

OBJECTIVE: The object of the study was to determine whether time of day, interval after a standard meal, and maternal body mass influence plasma glucose concentrations in women with gestational diabetes mellitus. STUDY DESIGN: Identical mixed meals were administered on 2 separate occasions 1 week apart to 30 women with dietarily treated gestational diabetes and pregnancies between 28 and 38 weeks' gestation. One meal was administered at 7 AM (morning meal) and the other was administered at 9 PM (evening meal), each after a fast of >/=5 hours. The order of the meals (morning first versus evening first) was assigned randomly. Sixteen of the women had a body mass index >/=27 kg/m(2) (overweight) and 14 women had a body mass index <27 kg/m(2) (lean). Venous plasma concentrations of glucose, insulin, free fatty acids, beta-hydroxybutyrate, and bound and free cortisol were measured hourly for 9 hours after each of the test meals. RESULTS: When all women were considered together glucose concentrations after the morning meal were significantly greater at 1 hour, were not different at 2 hours, and were significantly lower from 3 through 9 hours postprandially than those at corresponding times after the evening meal. Plasma beta-hydroxybutyrate and free fatty acid concentrations were higher between 5 and 9 hours after the morning meal than at the same times after the evening meal. Total and free cortisol levels were higher for the first 7 hours after the morning feeding, reflecting known diurnal variation in cortisol concentrations. Overweight patients' glucose values were significantly greater than those of lean subjects during the last 4 hours of the overnight fast. CONCLUSIONS: Among women with dietarily treated gestational diabetes the glucose concentrations were significantly higher from 3 to 9 hours after an evening meal, whereas suppression of free fatty acids and beta-hydroxybutyrate was less sustained after a morning feeding. The mechanisms underlying these differences remain to be determined but may involve diurnal influences of counterregulatory hormones. The relationships between measurements of maternal glycemia and maternal and perinatal outcomes in pregnancies complicated by gestational diabetes may be clarified by establishing a uniform duration of a fast and by developing meal-specific preprandial and postprandial maternal glucose targets for these patients.