Atlantic DIP: subject recruitment, data collection, missing data management and analysis procedures.

This paper describes the experiences related to the universal screening study for gestational diabetes mellitus (GDM) with reference to the subject recruitment process, data collection processes, (data entry, editing, quality assurance) and statistical analysis including the importance of missing data.

New estimates of the costs of universal screening for gestational diabetes mellitus in Ireland.

The new International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria have been predicted to increase the prevalence of gestational diabetes mellitus 2-to-3 fold and will have important resource implications for healthcare systems. A bottom-up, prevalence-based analysis was undertaken to estimate the costs of universal screening for gestational diabetes mellitus in Ireland using the new criteria. Healthcare activity was identified from the Atlantic Diabetes in Pregnancy database and grouped into five categories: (i) screening and testing, (ii) GDM treatment, (iii) prenatal care, (iv) delivery care, and (v) neonatal care. When individual resource components were valued using unit cost data and aggregated, the total healthcare cost was estimated at Euro 46,311,301 (95% CI: Euro 36,381,038, Euro 68,007,432). The average cost per case detected was Euro 351 (95% CI: (Euro 126, Euro 558) and the average total cost per case detected and treated was Euro 9,325 (95% CI: Euro 5,982, Euro 13,996). Further research is required to determine the cost effectiveness of screening in the region with a view to improving resource allocation in this area in the future.

Is there a socioeconomic gradient in the prevalence of gestational diabetes mellitus?

Previous studies have shown an association between Type 2 diabetes and lower socioeconomic status. This link is less clear in those with gestational diabetes mellitus (GDM). We test for a socioeconomic gradient in the prevalence of GDM by analysing data on 9,842 pregnant women who were offered testing for GDM in the Atlantic Diabetes in Pregnancy universal screening programme. A bivariate probit model relating GDM prevalence to socioeconomic status was estimated, controlling for variation in screening uptake rates across socioeconomic groups. The estimated increased prevalence of GDM is 8.6% [95% CI 2.7%-12.0%] for women in the lowest socioeconomic group when compared to the highest, suggesting a strong socioeconomic gradient in the prevalence of GDM. This gradient is found to be driven by differences in personal, clinical and lifestyle factors across socioeconomic groups.

Moderate and extreme maternal obesity.

The aim of this study was to investigate the prevalence of moderate and extreme obesity among an Irish obstetric population over a 10-year period, and to evaluate the obstetric features of such pregnancies. Of 31,869 women delivered during the years 2000-2009, there were 306 women in the study group, including 173 in the moderate or Class 2 obese category (BMI 35-39.9) and 133 in the extreme or Class 3 obese category (BMI > or = 40).The prevalence of obese women with BMI > or = 35 was 9.6 per 1000 (0.96%), with an upward trend observed from 2.1 per 1000 in the year 2000, to 11.8 per 1000 in the year 2009 (P = 0.001). There was an increase in emergency caesarean section (EMCS) risk for primigravida versus multigravid women, within both obese categories (P < 0.001). However, there was no significant difference in EMCS rates observed between Class 2 and Class 3 obese women, when matched for parity. The prevalence of moderate and extreme obesity reported in this population is high, and appears to be increasing. The increased rates of abdominal delivery, and the levels of associated morbidity observed, have serious implications for such women embarking on pregnancy.

Changing clinical practice can improve clinical outcomes for women with pre-gestational diabetes mellitus.

Prospective evaluation of pregnancy outcomes in women with pre-gestational diabetes over 6 years. The ATLANTIC Diabetes in Pregnancy group represents 5 antenatal centres along the Irish Atlantic seaboard, providing care for women with diabetes throughout pregnancy. In 2007 the group published a report that recognised that women were poorly prepared for pregnancy and that outcomes were sub-optimal. A change in practice occurred, offering women specialist-led, evidence-based care, both pre-pregnancy and combined antenatal/diabetes clinics during pregnancy. We now compare outcomes from 2005-2007 with 2008-2010. There was an increase in the numbers attending pre-conception care. Glycemic control before and throughout pregnancy improved. There was an overall increase in live births and decrease in perinata mortality rate. There was a decrease in large-for-gestational-age babies in mothers with Type 1 Diabetes. Elective Caesarean section rates increased while emergency section rates decreased. More women had Type 2 diabetes over time and these women were more likely to be obese. Changing the process of clinical care delivery can improve outcomes in for women with pre-gestational diabetes.

The impact of maternal obesity on gestational outcomes.

To investigate the effects of raised maternal BMI on pregnancy outcome in glucose tolerant women, using the IADPSG criteria. Prospective observational study of fetal and maternal outcome in a cohort of pregnant women recruited to a universal screening programme for gestational diabetes under the ATLANTIC-DIP partnership. Maternal outcomes included glucose, delivery mode, pregnancy induced hypertension (PIH), preeclampsia (PET), antepartum hemorrhage (APH) and postpartum hemorrhage (PPH). Fetal outcomes included birthweight, congenital malformation, fetal death, neonatal jaundice, hypoglycemia and respiratory distress. Increasing maternal BMI was associated with adverse pregnancy outcomes: higher cesarean section rates, pre-eclamptic toxemia, pregnancy induced hypertension, increased birth weight and congenital malformation. There was also an association between normal range glucose and emergency cesarean section, hypertension of pregnancy and birthweight. In spite of tightening criteria for hyperglycemia during pregnancy, raised BMI is associated with adverse pregnancy outcome.

Breast-feeding is associated with reduced postpartum maternal glucose intolerance after gestational diabetes.

Gestational diabetes mellitus (GDM) is associated with adverse foetal and maternal outcomes, and identifies women at risk of future Type 2 Diabetes Mellitus (T2DM). Breast-feeding may improve postpartum maternal glucose tolerance. We prospectively examined the prevalence of postpartum dysglycaemia after GDM and examined the effect of lactation on postpartum glucose tolerance. We compared postpartum 75g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT). Breast-feeding data was collected at time of OGTT. Postpartum OGTT results were classified as normal [fasting plasma glucose (FPG) < 5.6mmol/l, 2-h < 7.8 mmol/l] and abnormal [impaired fasting glucose (IFG), FPG 5.6-6.9 mmol/l; impaired glucose tolerance (IGT), 2-h glucose 7.8-11 mmol/l; IFG+IGT; T2DM, FPG > or = 7 mmol/l +/- 2h glucose > or = 11.1 mmol/l]. 6 (2.7%) with NGT in pregnancy had postpartum dysglycaemia compared to 57 (19%) with GDM in index pregnancy (p < 0.001). Non-European ethnicity (OR 3.40, 95% CI 1.45-8.02, p = 0.005), family history of T2DM (OR 2.14, 95% CI 1.06-4.32, p = 0.034) and gestational insulin use (OR 2.62, 95% CI 1.17-5.87 p = 0.019) were associated with persistent dysglycaemia. The prevalence of persistent hyperglycaemia was significantly lower in women who breast-fed versus bottle-fed postpartum (8.2% v 18.4%, p < 0.001). Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.

ATLANTIC DIP: pregnancy outcomes for women with type 1 and type 2 diabetes.

ATLANTIC DIP prospectively evaluated the perinatal and maternal outcomes of pregnancies complicated by Type 1 and Type 2 diabetes during 2006/2007 in 5 antenatal centres. All women with established diabetes for at least 6 months prior to the index pregnancy and booking for antenatal care between 1/1/2006 and 31/12/2007 were included in the study. Results were collected electronically via the DIAMOND Diabetes Information System. Pregnancy outcome was compared with that of the background population receiving antenatal care in the region during the same time. There were 104 singleton pregnancies during the period of study. The stillbirth rate (SBR) of 25/1000 was 5 times greater than that reported in the background population at 5/1000 and the perinatal mortality rate (PMR) of 25/1000 was 3.5 times greater than background 7/1000. The congenital malformation rate (CMR) of 24/1000 was twice that observed in the background population. Women were not well prepared for pregnancy with 28% receiving pre pregnancy care (PPC), 43% receiving pre pregnancy folic acid and 51% achieving a HbA1C < = 7% at first antenatal visit. Pregnancy induced hypertension (PIH) and/or pre eclampsia toxaemia (PET) were three times more common than in women in the background population. In conclusion women are not well prepared for pregnancy. Maternal and infant morbidity and infant mortality are greater in women with diabetes. A regional pre pregnancy care (PPC) programme and centralised glucose management are urgently needed.

Atlantic DIP: the prevalence and consequences of gestational diabetes in Ireland.

ATLANTIC DIP carried out a universal screening programme for gestational diabetes mellitus (GDM) along the Irish Atlantic seaboard. Using a 75g OGTT and new International Association of Diabetes in Pregnancy Study Groups (IADPSG) cut off points for diagnosis we found the prevalence of GDM to be 12.4%. Pregnancies complicated by GDM displayed increased morbidities for mother and infant when compared to women who had normal glucose tolerance. With rising obesity levels and older age of mothers, both risk factors for GDM, these results would support a national universal screening programme.

Psychological stress associated with diabetes during pregnancy: a pilot study.

Gestational Diabetes Mellitus (GDM) affects approximately 12% of women. The impact of a diagnosis of GDM may lead to increased stress in pregnancy due to the demands of adherence to a treatment regimen and maternal concern about adverse outcomes for the mother and baby. We examined the psychosocial profile of 25 women with gestational diabetes mellitus (GDM) and compared them to 25 non-diabetic pregnant women. Measures administered included the Pregnancy Experiences Scale (PES), the Depression, Anxiety Stress Scale (DASS), the Problem Areas in Diabetes Scale (PAID-5) and the Perceived Social Support Scale (PSSS). The GDM group reported a significantly greater ratio of pregnancy 'hassles' to pregnancy 'uplifts'. The GDM group also had a significantly higher Depression score and were twice as likely to score above the cut-off for possible depression. Elevated levels of diabetes-related distress were found in 40% of women with GDM. In addition, the GDM group reported less social support from outside the family. Our preliminary study indicates that the experience of GDM appears to be associated with increased psychological distress in comparison to the experience of non-diabetic pregnant women. This may indicate the need for psychological screening in GDM and the provision of psychological support in some cases.

Trimester-specific reference intervals for IFCC standardised haemoglobin A(1c): new criterion to diagnose gestational diabetes mellitus (GDM)?

We established trimester-specific reference intervals for IFCC standardised HbA(1c) in 311 non-diabetic Caucasian pregnant women (n = 246) and non-pregnant women (n = 65). A selective screening strategy based on risk factors for gestational diabetes was employed. Pregnancy trimester was defined as trimester 1 (T1, n = 40) up to 12 weeks + 6 days, trimester 2 (T2, n = 106) 13 to 27 weeks + 6 days, trimester 3 (T3, n = 100) > 28 weeks to delivery. The normal HbA(1c) reference interval for Caucasian non-pregnant women was 29-37 mmol/mol (DCCT: 4.8-5.5%), T1: 24-36 mmol/mol (DCCT: 4.3-5.4%), T2: 25-35 mmol/mol (DCCT: 4.4-5.4%), and T3: 28-39 mmol/mol (DCCT: 4.7-5.7%). HbA(1c) was significantly decreased in trimesters 1 (P < 0.01) and 2 (P < 0.001) compared to non-pregnant women. Retrospective application of selective screening to Caucasian women of the Atlantic DIP cohort determined that 5,208 met the criteria. 945 of those women (18.1%) were diagnosed with Gestational Diabetes Mellitus (GDM) using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) glucose concentration thresholds. HbA(1c) measurement within 2 weeks of the diagnostic Oral Glucose Tolerance Test (OGTT) was available in 622 of 945 (66%). Applying the decision threshold for T2: HbA(1c) > 35 mmol/mol (DCCT > 5.4%) identified 287 of 622 (46%) of those with GDM. HbA(1c) measurement in T2 (13 to 27 weeks) should be included in the diagnostic armamentarium for GDM. This would reduce the need for diagnostic OGTT in a significant number of women.

Atlantic Diabetes in Pregnancy (DIP): the prevalence and outcomes of gestational diabetes mellitus using new diagnostic criteria.

AIMS/HYPOTHESIS: New diagnostic criteria for gestational diabetes mellitus (GDM) have recently been published. We wished to evaluate what impact these new criteria would have on GDM prevalence and outcomes in a predominantly European population. METHODS: The Atlantic Diabetes In Pregnancy (DIP) programme performed screening for GDM in 5,500 women with an oral glucose tolerance test at 24-28 weeks. GDM was defined according to the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and compared with previous WHO criteria; maternal and neonatal adverse outcomes were prospectively recorded. RESULTS: Of the participants, 12.4% and 9.4% were diagnosed with GDM using IADPSG and WHO criteria, respectively. IADPSG GDM pregnancies were associated with a statistically significant increased incidence of adverse maternal outcomes (gestational hypertension, polyhydramnios and Caesarean section) and neonatal outcomes (prematurity, large for gestational age, neonatal unit admission, neonatal hypoglycaemia and respiratory distress). The odds ratio for the development of these adverse outcomes remained significant after adjustment for maternal age, body mass index and non-European ethnicity. Those women who were classified as having normal glucose tolerance by WHO criteria but as having GDM by IADPSG criteria also had significant adverse pregnancy outcomes. CONCLUSIONS/INTERPRETATION: GDM prevalence is higher when using newer IADPSG, compared with WHO, criteria, and these women and their offspring experience significant adverse pregnancy outcomes. Higher rates of GDM pose a challenge to healthcare systems, but improved screening provides an opportunity to attempt to reduce the associated morbidity for mother and child.

The cost of universal screening for gestational diabetes mellitus in Ireland.

AIMS: To estimate the costs associated with universal screening for gestational diabetes mellitus in Ireland. METHODS: Bottom-up, prevalence-based cost analysis. Healthcare activity identified using the Atlantic Diabetes in Pregnancy (ATLANTIC DIP) database was grouped into five categories: screening and testing, gestational diabetes treatment, prenatal care, delivery care and neonatal care. A vector of unit cost data (euros in 2008 prices) was applied to specified resource use and the total healthcare cost calculated. A series of one-way and probabilistic sensitivity analyses were undertaken to explore the uncertainty in the analysis. RESULTS: When individual resource components were valued and aggregated, the total healthcare cost of gestational diabetes in Ireland was estimated at €12 433 320 (95% CI €9 298 228-16 778 193). The average cost per case detected was €1621 (95% CI €524-2603) and the average total cost per case detected and treated was €11 903 (95% CI €7645-16 121). CONCLUSIONS: This research provides the first estimates of the healthcare costs associated with gestational diabetes mellitus in Ireland. Further research is required to determine the cost-effectiveness of gestational diabetes screening in the region with a view to improving resource allocation in this area in the future.

Traveller health: prevalence of diabetes, pre diabetes and the metabolic syndrome.

Irish Travellers are an ethnic minority group exposed to a myriad of social and health inequalities. Their current life expectancy equals that of the background population in the 1940s and one of the main causes of death is cardiovascular disease (CVD). There is a paucity of information on CVD risk factor assessment in the research literature in this population. This study assesses the prevalence of Diabetes, Pre-Diabetes and the Metabolic Syndrome (MetS) in a sample population from this community. Working with the Galway Traveller Movement, and following an overnight fast we measured fasting plasma glucose, HDL-cholesterol and Triglycerides. In addition weight, height, waist circumference (WC) and blood pressure (BP) were recorded. Of the 47 subjects, there were 4 (8.5%) participants identified as having diabetes, 5 (10.6%) pre-diabetes and 25 (53.2%) with the metabolic syndrome. The point prevalence of diabetes was calculated as 8.5%, pre-diabetes 10.6% and the metabolic syndrome 53.2%. In addition abdominal obesity was present in 70% and hypertension in 43%. Targeted screening for glucose abnormalities and traditional CVD risk factors is needed. Based on current literature, appropriate interventions might reasonably be expected to lower mortality and increase life expectancy.

Determining the quality of the medical educational environment at an Irish medical school using the DREEM inventory.

A Cross-Sectional study using the already validated Dundee Ready Educational Environment (DREEM) questionnaire was used to assess the Undergraduate Medical Educational Environment in an Irish Medical School during the first semester 2004/2005. 389 of 476 students (82%) completed the questionnaire. The mean total score was 130 out of a maximum of 200 (65%) indicating relative satisfaction with the environment but with room for improvement. There were no individual areas of excellence identified. The following two areas were identified as being problematic (a) lack of a support system for stressed students (b) over emphasis on memorization of facts. These areas were perceived by clinical students to be greater when compared to pre-clinical students. Female students appeared happier in their environment but male students were more confident about passing exams. Non-Irish students had a lower overall score when compared to Irish students. The DREEM is a useful tool to assess the overall teaching environment and highlight areas of weakness. Use of DREEM as a monitoring tool would be useful to re-evaluate the environment following appropriate intervention.

The prevalence of Down syndrome in County Galway.

This is a retrospective survey of all cases of Down syndrome recorded between 1981 and 2000 to mothers resident in Co. Galway. The study compares the incidence of Down syndrome in both decades and examines the effects of changing demographics on incidence rates. The overall prevalence rate was 26.8/10,000 live births for the full period. Although there were 5119 fewer births in the 1991-2000 period, the prevalence was 29.8/10,000 compared to 24.1/10,000 in the previous decade. Despite the falling birth rates and fertility rates observed in our study between the two decades we found that the higher prevalence of Down syndrome in the second decade was directly related to the significant increase in the proportion of women in the 30 plus age group. Our study also found the place of the child with Down syndrome in the family changed, with 25.3% being the 5th or more child in the first decade compared with 9.5% in the second decade.

A survey of asylum seekers' general practice service utilisation and morbidity patterns.

To compare Irish asylum seekers to other General Medical Scheme (GMS) patients possessing Irish citizenship in terms of their utilisation of GP services, morbidity patterns and consultation outcomes. A retrospective 1 year study on patient records in two Galway City practices was performed. All asylum seekers who were patients of the two practices were compared with two controls each from a population of GMS patients with Irish citizenship matched for age, sex, and GMS status. Demographic information was recorded. For each consultation over the 12 months the diagnosis using the ICPC coding system' and consultation outcomes were recorded. Data was collected on 171 asylum seekers and 342 Irish citizens. The majority of asylum seekers registered in the two practices were from Nigeria (43.9%). The age of cases ranged from 1 month to 60 years of age with a median of 26. 45.8% were female and 54% male. The mean number of visits per asylum seeker per year was 5.16 (SD 3.12) whereas the mean for Irish Citizens was 2.31 (SD 2.33) (p = 0.0001). Asylum seekers had a significantly higher likelihood of being assigned diagnoses in the disease systems of psychiatry, dermatology, neurology, muscuioskeletal disease, urology, respiratory, ENT, Obstetrics and Gynaecology and gastroenterology. Asylum seekers were five times more likely to be diagnosed with psychiatric illness than Irish citizens. Specifically they had a significantly higher chance of being diagnosed with anxiety (odds ratio = 3.17 [95% CI 1.1,8.68]). Overall, the frequency of prescription as a consultation outcome was higher for asylum seekers. Asylum seekers were prescribed more antibiotics and psychiatric medications but Irish GMS had higher prescription rates for drugs outside of these categories. Referral rates were higher in the asylum seeker group. Asylum seekers attended the GP more frequently than their Irish counterparts. They were more likely to be diagnosed with psychological problems than the Irish. Studies have shown a strong link between psychological illness and being a "frequent attender" in general practice. This could explain the higher than average frequency of attendance in this group. They were more likely to be prescribed antibiotics and psychiatric medications. This study provides the first quantitative data to inform debate regarding the appropriate supply of resources to Irish practices with significant numbers of asylum seekers.

The Lifeways Cross-Generation Study: design, recruitment and data management considerations.

The Lifeways Cross-Generation Cohort Study was first established in 2001 and is a unique longitudinal database in Ireland, with currently over three and a half thousand family participants derived from 1124 mothers recruited initially during pregnancy, mainly during 2002. The database comprises a) baseline self-reported health data for all mothers, a third of fathers and at least one grandparent b) clinical hospital data at recruitment, c) three year follow-up data from the families' General Practitioners, and d) linkage to hospital and vaccination databases. Data collection for the five-year follow-up with parents is underway, continuing through 2007. Because there is at present no single national/regional health information system in Ireland, original data instruments were designed to capture data directly from family members and through their hospitals and healthcare providers. A system of relational databases was designed to coordinate data capture for a complex array of study instruments and to facilitate tracking of family members at different time points.