Progression of diabetic retinopathy in women with pregestational diabetes during pregnancy and postpartum.

BACKGROUND: Diabetic retinopathy (DR) may worsen during pregnancy, but its course in the postpartum remains poorly understood. Understanding the natural history of DR during and after pregnancy can help determine when sight-threatening DR treatment should be administered. METHODS: A prospective longitudinal cohort study recruited pregnant women with pre-existing type 1 (T1D) or type 2 diabetes from two tertiary Diabetes Antenatal Clinics in Melbourne, Australia. Eye examination results in early pregnancy, late pregnancy, and up to 12-months postpartum were compared to determine DR changes. Two-field fundus photographs and optical coherence tomography scans were used to assess DR severity. RESULTS: Overall, 105 (61.4%) women had at least two eye examinations during the observation period. Mean age was 33.5 years (range 19-51); 54 women (51.4%) had T1D; 63% had HbA1c <7% in early pregnancy. DR progression rate was 23.8% (95% CI 16.4-32.6). Having T1D (RR 4.96, 95% CI 1.83-13.46), pre-existing DR in either eye (RR 4.54, 95% CI 2.39-8.61), and elevated systolic blood pressure (adjusted RR 2.49, 95% CI 1.10-5.66) were associated with increased risk of progression. Sight-threatening progression was observed in 9.5% of women. Among the 19 eyes with progression during pregnancy, 15 eyes remained stable, three eyes progressed, and only one eye regressed in the postpartum. CONCLUSIONS: Nearly 1 in 4 women had DR progression from conception through to 12-months postpartum; almost half of these developing sight-threatening disease. DR progression occurring during pregnancy was found to predominantly remain unchanged, or worsen, after delivery, with very few eyes spontaneously improving postpartum.

Prevalence of diabetic retinopathy in women with pregestational diabetes during pregnancy and the postpartum.

BACKGROUND: Diabetic retinopathy (DR) may be affected by pregnancy. The majority of prevalence data regarding DR in pregnancy predate the advent of contemporary guidelines for diabetes management during pregnancy. This study reports DR prevalence and associated risk factors in women with pregestational diabetes during pregnancy and the postpartum in Australia. METHODS: A total of 172 pregnant women with type 1 (T1DM) or type 2 diabetes diagnosed pre-pregnancy were prospectively recruited from two obstetrics hospitals in Melbourne (November 2017-March 2020). Eye examinations were scheduled in each trimester, at 3-, 6-, and 12-months postpartum. DR severity was graded from two-field fundus photographs by an independent grader utilising the Airlie House Classification. Sight-threatening DR (STDR) was defined as the presence of diabetic macular oedema or proliferative DR. RESULTS: Overall, 146 (84.9%) women had at least one eye examination during pregnancy. The mean age was 33.8 years (range 19-51), median diabetes duration was 7.0 years (IQR 3.0-17.0), 71 women (48.6%) had T1DM. DR and STDR prevalence during pregnancy per 100 eyes was 24.3 (95% CI 19.7-29.6) and 9.0 (95% CI 6.1-12.9); while prevalence in the postpartum was 22.2 (95% CI 16.5-29.3) and 10.0 (95% CI 5.4-17.9), respectively. T1DM, longer diabetes duration, higher HbA1c in early pregnancy, and pre-existing nephropathy were significant risk factors. CONCLUSIONS: The prevalence of DR in pregnant women was similar to the non-pregnant diabetic population in Australia. One in nine participants had STDR during pregnancy and the postpartum, highlighting the need to optimise DR management guidelines in pregnancy given the significant risk of vision loss.

Working with young people: evaluation of an education resource for medical trainees.

AIM: Many health professionals report interest in consulting more effectively with young people but have unmet training needs. We set out to evaluate a teaching resource in adolescent health and medicine that was designed for Australian trainees in specialist medicine. METHODS: Thirty-two paediatric and adult trainees of the Royal Australasian College of Physicians completed a pre-evaluation questionnaire to assess attitudes and confidence in working with young people. They were then provided with a training resource and, 6 weeks later, completed a post-evaluation questionnaire. Repeated-measures anovas were used to assess changes in attitudes, self-reported knowledge and confidence by trainee type. χ(2) -tests were used to compare variation in the use of and opinions about the resource. RESULTS: Trainees' awareness of the health issues that affect young people, confidence in working with young people and confidence in their knowledge greatly improved after using the resource. Beforehand, adult medicine trainees scored lower than paediatric trainees. A relatively higher rate of improvement resulted in similar scores between trainee types after using the resource, which was rated equally highly by the different groups of trainees. CONCLUSIONS: As a result of significant gains in the confidence of specialist medicine trainees after access to the resource, it will now be made available for Australian trainees in specialist medicine.

Simulation in clinical teaching and learning.

Simulation-based education (SBE) is a rapidly developing method of supplementing and enhancing the clinical education of medical students. Clinical situations are simulated for teaching and learning purposes, creating opportunities for deliberate practice of new skills without involving real patients. Simulation takes many forms, from simple skills training models to computerised full-body mannequins, so that the needs of learners at each stage of their education can be targeted. Emerging evidence supports the value of simulation as an educational technique; to be effective it needs to be integrated into the curriculum in a way that promotes transfer of the skills learnt to clinical practice. Currently, SBE initiatives in Australia are fragmented and depend on local enthusiasts; Health Workforce Australia is driving initiatives to develop a more coordinated national approach to optimise the benefits of simulation.

Clinical teaching and learning: from theory and research to application.

Learning in the clinical setting is the cornerstone of medical school education, but there are strong imperatives to optimise the ways in which students acquire clinical expertise. Deliberate practice is characterised by attention, concentration, effort and repetition of skills; it is an important tool for developing and maintaining professional expertise. Research has led to a greater understanding of how medical students develop core clinical skills, especially in the areas of diagnostic reasoning, communication and physical examination. Advances in information technology and instructional design are helping to strengthen the links between formal educational activities and opportunistic learning in the clinical setting.

Comparing the academic performance of graduate- and undergraduate-entry medical students.

OBJECTIVE: This study compared the academic performance of graduate- and undergraduate-entry medical students completing the same pre-clinical curriculum and assessment at a large metropolitan university. Arguments have been made for the relative merits of both graduate- and undergraduate-entry medical programmes. However, data on the academic performance of graduate and undergraduate entrants are relatively scarce. METHODS: This retrospective study adopted a quasi-experimental design to compare data from assessments of bioscience knowledge and clinical skills undertaken across 2 years for four cohorts of medical students (who commenced their studies between 2002 and 2005). Percentage final results for four bioscience knowledge subjects and four clinical skills assessments (based on objective structured clinical examination [OSCE] results) were compared for 240 graduates and 464 undergraduates using multivariate analysis of variance (manova). RESULTS: Graduate-entry students performed marginally better than undergraduate-entry students on all four bioscience knowledge assessments (partial eta-squared [n(p)(2)], n(p)(2)=0.04) and also on early clinical skills assessments (n(p)(2)=0.06). CONCLUSIONS: Graduate-entry students had a marginal academic performance advantage during the early years of this medical course. Most graduate-entry students had a first degree in a science discipline; thus their advantage may be explained by prior bioscience knowledge. Their performance advantage in clinical skills is less easily attributed to prior learning. Instead, this result provides some evidence for a possible advantage related to age. The marginal differences in early academic and clinical performance probably suggest that both graduate and undergraduate entry should exist in parallel to preserve multiple points of entry to the medical profession.

Position statement of the Australian Diabetes Society: individualisation of glycated haemoglobin targets for adults with diabetes mellitus.

Tight glycaemic control reduces the risk of development and progression of organ complications in people with type 1 or type 2 diabetes. In this position statement, the Australian Diabetes Society recommends a general target glycated haemoglobin (HbA(1c)) level of

Building capacity in medical education research in Australia.

Medical education research is a relatively new but growing discipline. There is an overall perception of lack of confidence in the quality of the research, which is not entirely justified. The scientific quality of any research is defined by the appropriate application of method to a particular problem. There is a need for programmatic research focused on developing medical education policy. University medical education units need to be research-focused. Medical Deans Australia and New Zealand and the Australian and New Zealand Association of Medical Education (ANZAME: the Association for Health Professional Education) can provide leadership. Funding bodies need to develop their relationship with medical education research.

Neonatal hyperinsulinaemic hypoglycaemia and monogenic diabetes due to a heterozygous mutation of the HNF4A gene.

Recent research has demonstrated that mutations of the hepatocyte nuclear factor 4-alpha (HNF4A) gene are associated with neonatal hyperinsulinaemic hypoglycaemia. Mutations of this gene also cause one of the subtypes of monogenic diabetes, a form of diabetes formerly known as maturity-onset diabetes of the young. This article describes a family discovered to have a novel frame-shift mutation of the HNF4A gene in the setting of early-onset maternal diabetes and severe neonatal hyperinsulinaemic hypoglycaemia. The implications of a diagnosis of HNF4A gene mutation for obstetric and paediatric practice are discussed.

Persistent hyperinsulinemic hypoglycemia and maturity-onset diabetes of the young due to heterozygous HNF4A mutations.

OBJECTIVE: Mutations in the human HNF4A gene encoding the hepatocyte nuclear factor (HNF)-4alpha are known to cause maturity-onset diabetes of the young (MODY), which is characterized by autosomal-dominant inheritance and impaired glucose-stimulated insulin secretion from pancreatic beta-cells. HNF-4alpha has a key role in regulating the multiple transcriptional factor networks in the islet. Recently, heterozygous mutations in the HNF4A gene were reported to cause transient hyperinsulinemic hypoglycemia associated with macrosomia. RESEARCH DESIGN AND METHODS: Three infants presented with macrosomia and severe hypoglycemia with a positive family history of MODY. The hypoglycemia was confirmed to be due to hyperinsulinism, and all three patients required diazoxide therapy to maintain normoglycemia. Two of the three infants are still requiring diazoxide therapy at 8 and 18 months, whereas one of them had resolution of hyperinsulinemic hypoglycemia at 32 months of age. RESULTS: Sequencing of the HNF4A gene identified heterozygous mutations in all three families. In family 1, a frameshift mutation L330fsdel17ins9 (c.987 1003del17ins9; p.Leu330fs) was present in the proband; a mutation affecting the conserved A nucleotide of the intron 2 branch site (c.264-21A>G) was identified in the proband of family 2; and finally a nonsense mutation, Y16X (c.48C>G, p.Tyr16X), was found in the proband of family 3. CONCLUSIONS: Heterozygous HNF4A mutations can therefore cause both transient and persistent hyperinsulinemic hypoglycemia associated with macrosomia. We recommend that macrosomic infants with transient or persistent hyperinsulinemic hypoglycemia should be screened for HNF4A mutations if there is a family history of youth-onset diabetes.

A training agenda in adolescent medicine and health.

The complexity of health issues facing young people, an appreciation that problems arising in adolescence may have long term implications for health, and greater confidence about the value of clinical intervention are key factors underpinning current efforts in Australia to build an education agenda for health professionals working with young people. This paper outlines a series of education initiatives in both undergraduate and postgraduate settings and discusses the growing support for more strategic and coherent approaches to education nationally. In particular, efforts to improve the capacity of health professionals to work with young people are described, together with the opportunity for more focused subspeciality training in Adolescent Medicine. Within our region and beyond, Australia is increasingly being turned to as a model of academic leadership in adolescent medicine, including professional education and training. In Australia, this has been best achieved by centres of excellence in adolescent health.

The transition from knowing to doing: teaching junior doctors how to use insulin in the management of diabetes mellitus.

OBJECTIVE: To develop and evaluate a short education programme to improve the skills and confidence of junior doctors in managing the glycaemic control of inpatients with diabetes mellitus. METHODS: A total of 15 junior doctors completed two 1-hour workshops on the practical skills required to manage the glycaemic control of insulin-treated patients. The workshops were based on simulated case scenarios presented in a workbook format. Pre-workshop performance and levels of confidence were tested, using a set of tasks matched to the learning objectives. Participants were re-tested immediately after the second workshop and again after 3 months. RESULTS: There was a significant overall effect for time of testing for performance and confidence considered together, F(4,11) = 12.67, P = 0.000, power = 1.00. The mean score for performance for the intermediate and 3-month post-tests combined was significantly higher than the mean performance score for the pre-test (11.00 < [17.53 + 15.80]), t(56) = -6.50, P = 0.000 (95% CI -6.15, -3.10). The mean score for confidence for the intermediate and 3 month post-tests combined was higher than the mean for the pre-test (13.20 < [15.33 + 15.20]), t(56) = 2.95, P = 0.011 (95% CI 2.19, 0.46), although this result must be treated with caution. CONCLUSIONS: A brief educational intervention can improve and maintain the performance and confidence of junior doctors in managing patients with insulin-treated diabetes in a simulated environment.

What can clinical teachers learn from Harry Potter and the Philosopher's Stone?

Many clinical teachers acquire a working knowledge of the principles of teaching and learning through observation, by adopting positive and rejecting negative examples of clinical instruction. Well selected vignettes of teaching behaviours taken from contemporary film and literature may provide rich substrate by which to engage clinical teachers in discourse about instructional technique. This paper draws on J K Rowling's novel and its companion film, Harry Potter and the Philosopher's Stone, and critically analyses the teaching styles of the staff at Hogwarts School of Wizardry and Witchcraft in the context of contemporary generic and medical education literature. Specifically, it argues that effective teachers demonstrate not only an in-depth knowledge of their discipline but possess a keen appreciation of the cognitive changes that occur in their students during the learning process. They are, furthermore, proficient in core instructional skills such as small group facilitation, feedback and questioning. Most importantly, effective teachers model appropriate attitudes in their professional setting and possess highly developed personal qualities such as creativity, flexibility and enthusiasm.