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.

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.

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.

Guidelines for using insulin lispro.

OBJECTIVE: To review the best evidence-based literature on the insulin analogue, lispro insulin, and to provide guidelines for its use. QUALITY OF EVIDENCE: Using the MeSH terms, lispro and insulin analogues, we searched PubMed, Current Contents, MEDLINE, and EMBASE from January 1986 to July 1998 and selected 42 articles out of 97 for high quality and relevance to family medicine. Twenty-eight were randomized controlled trials, but only two studies were blinded because lispro and regular insulin have different optimal times of administration. MAIN MESSAGE: The new insulin analogue, lispro, produces a much more rapid, higher, and shorter-lasting peak level of insulin than regular human insulin, thus mimicking physiologic secretion of insulin more closely. This allows insulin administration just before or just after meals and means patients can manage with fewer snacks. Lispro controls postprandial blood glucose levels better and does not cause hypoglycemia. Although most older studies showed no change in glycosylated hemoglobin (HbA1c) levels, a few recent studies involving refinements, such as continuous subcutaneous insulin infusion or basal insulin to reduce preprandial glucose levels, have found small but significant improvements. Insulin lispro has also been used successfully in cases of insulin resistance and insulin allergy. CONCLUSIONS: Lispro is a useful addition for motivated diabetic patients who like to achieve better control of HbA1c without increased hypoglycemia and to match mealtime insulin injections with diet, exercise, and various lifestyles.

Insulin lispro (Humalog), the first marketed insulin analogue: indications, contraindications and need for further study.

OBJECTIVE: To review the available literature on the new insulin analogue insulin lispro and provide information on its efficacy, indications for use and contraindications. DATA SOURCES: MEDLINE searches were made for articles published from 1966 to 1996 using the indexing term "lispro", "Humalog" and "insulin analogs". STUDY SELECTION: About 30 studies and review articles were selected based on their relevance to the stated objective. These were critically appraised for the purpose of writing the review article so that it would be relevant to general practitioners, internists and nurse educators. DATA SYNTHESIS: The therapeutic challenge when treating diabetic patients is to bring the blood glucose level into as normal a range as possible, with minimal hypoglycemia and hyperinsulinemia. Insulin lispro has a much faster, higher and shorter-lasting peak serum insulin level than regular human insulin, thus mimicking physiologic secretion of insulin more closely. As a result, there is improvement in postprandial blood glucose levels and decreased episodes of hypoglycemia, with no change in the hemoglobin A1c (HgbA1c) level. The ability to inject insulin lispro immediately before the meal allows greater flexibility of lifestyle. Compared with regular insulin, insulin lispro is associated with a lower risk of hypoglycemia with exercise several hours after a meal. It is therefore most useful for the motivated, compliant diabetic patient who would like to achieve a better hypoglycemia-HgbA1c ratio as well as for patients desiring further flexibility with premeal insulin injections. Use of insulin lispro has been shown to improve HgbA1c levels in patients using insulin pumps. It is well tolerated, and therapy is often continued after studies are completed. Further study is needed to establish optimal basal regimens.

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.

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.

Cardiopulmonary resuscitation decision making in long-term care: a role for the nurse?

In many long-term care settings, cardiopulmonary resuscitation (CPR) is regarded as an available treatment option. However, for the majority of long-term care residents the expected outcome following CPR is poor. This descriptive study explored the CPR decision-making process in two long-term care institutions. This was accomplished through the administration of questionnaires to nursing staff, residents, residents' family members and through completion of a chart review of deceased individuals. This paper primarily addresses the role of nurses in the CPR decision-making process in long-term care. Nurses were rarely explicitly involved in the CPR decision-making process. Knowledge deficits of nurses concerning the CPR policy at the institutions and the expected outcomes of CPR were identified. Also noted were inconsistencies between policy and practice, with CPR being withheld in practice more often than dictated by protocol. Strategies to facilitate the CPR decision-making process in long-term care settings are suggested, and specific roles for nurses in relation to CPR decision making are presented.

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.

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.

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.

'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.