Women's views on screening for Type 2 diabetes after gestational diabetes: a systematic review, qualitative synthesis and recommendations for increasing uptake.

AIM: Many women do not attend recommended glucose testing following a pregnancy affected by gestational diabetes (GDM). We aimed to synthesize the literature regarding the views and experiences of women with a history of GDM on postpartum glucose testing, focusing on barriers and facilitators to attendance. METHODS: We systematically identified qualitative studies that examine women's experiences following GDM relating to glucose testing (diabetes screening) or experience of interventions to promote uptake of testing. We conducted a thematic synthesis to develop descriptive and then analytical themes, then developed recommendations to increase uptake based on the findings. We evaluated the quality of each study and the confidence that we had in the recommendations using published checklists. RESULTS: We included 16 articles after screening 23 160 citations and 129 full texts. We identified four themes of influences relating to the healthcare system and personal factors that affected both ability and motivation to attend: relationship with health care, logistics of appointments and tests, family-related practicalities and concern about diabetes. We developed 10 recommendations addressing diabetes risk information and education, and changes to healthcare systems to promote increased attendance at screening in this population, most with high or moderate confidence. CONCLUSIONS: We have identified a need to improve women's understanding about Type 2 diabetes and GDM, and to adjust healthcare provision during and after pregnancy to decrease barriers and increase motivation for testing. Encouraging higher uptake by incorporating these recommendations into practice will enable earlier management of diabetes and improve long-term outcomes.

Barriers to completing oral glucose tolerance testing in women at risk of gestational diabetes.

AIM: Complications of gestational diabetes (GDM) can be mitigated if the diagnosis is recognized. However, some at-risk women do not complete antenatal diagnostic oral glucose tolerance testing (OGTT). We aimed to understand reasons contributing to non-completion, particularly to identify modifiable factors. METHODS: Some 1906 women attending a tertiary UK obstetrics centre (2018-2019) were invited for OGTT based on risk-factor assessment. Demographic information, test results and reasons for non-completion were collected from the medical record. Logistic regression was used to analyse factors associated with non-completion. RESULTS: Some 242 women (12.3%) did not complete at least one OGTT, of whom 32.2% (n = 78) never completed testing. In adjusted analysis, any non-completion was associated with younger maternal age [≤ 30 years; odds ratio (OR) 2.3, 95% confidence interval (CI) 1.6-3.4; P < 0.001], Black African ethnicity (OR 2.7, 95% CI 1.2-5.5; P = 0.011), lower socio-economic status (OR 0.9, 95% CI 0.8-1.0; P = 0.021) and higher parity (≥ 2; OR 1.8, 95% CI 1.1-2.8; P = 0.013). Non-completion was more likely if testing indications included BMI ≥ 30 kg/m2 (OR 1.7, 95% CI 1.1-2.4; P = 0.009) or family history of diabetes (OR 2.2, 95% CI 1.5-3.3; P < 0.001) and less likely if the indication was an ultrasound finding (OR 0.4, 95% CI 0.2-0.9; P = 0.035). We identified a common overlapping cluster of reasons for non-completion, including inability to tolerate test protocol (21%), social/mental health issues (22%), and difficulty keeping track of multiple antenatal appointments (15%). CONCLUSIONS: There is a need to investigate methods of testing that are easier for high-risk groups to schedule and tolerate, with fuller explanation of test indications and additional support for vulnerable groups.

The effect of sparging rate on transmembrane pressure and critical flux in an AnMBR.

Anaerobic membrane bioreactors (AnMBRs) have been shown to be successful units for the treatment of low strength wastewaters, however, the issue of membrane fouling is still a major problem in terms of economic viability. Biogas sparging has been shown to reduce fouling substantially, and hence this study monitored the effect of biogas sparging rate on an AnMBR. The critical flux under a sparging rate of 6 l per minute (LPM) was found to be 11.8 l m(-2) h(-1) (LMH), however, membrane hysteresis was found to have an effect on the critical flux, and where the AnMBR had previously been operated with a 2 LPM sparging rate, the critical flux fell to 7.2 LMH. The existence of a "critical sparging rate" was also investigated under the condition that 'there exists a sparging rate beyond which any further decrease in sparging rate will cause a dramatic rise in TMP'. For an AnMBR operating at a flux of 7.2 LMH the critical sparging rate was found to be 4 LPM.

Endogenous inhibitors of monoamine oxidase present in human cerebrospinal fluid.

Inhibitory activity against the enzyme monoamine oxidase is present in low molecular weight fractions (less than 100,000) of human cerebrospinal fluid. These endogenous substances of different molecular weights (3000 to more than 35,000) act like monoamine oxidase inhibitor drugs to inhibit both type A and type B monoamine oxidase.

A simple method to measure proton beam energy in a standard medical cyclotron.

A simple and rapid technique to measure the proton beam energy in the external beam line of a medical cyclotron has been examined. A stack of 0.1 mm thick high purity copper (Cu) foils was bombarded and the relative activity of 65Zn produced in each foil was compared to a computational model that predicted activity, based on proton stopping power, reaction cross-sectional data, and beam energy. In the model, the beam energy was altered iteratively until the best match between computed and measured relative activities of the stack of disks was obtained. The main advantage of this method is that it does not require the comparison of the activities of different isotopes of zinc arising from (p, xn) reactions in the Cu, which would require the gamma photon detector being calibrated for different energy responses. Using this technique the proton beam energy of a nominally 18 MeV standard isochronous medical cyclotron was measured as 17.49 +/- 0.04 (SD) MeV, with a precision of 0.2% CV.

Can current models explain the lack of liver complications in Y-90 microsphere therapy?

Normal liver complications have not been observed in Y-90 microsphere therapy of hepatic tumors [selective internal radiation (SIR)], despite clinical studies reporting estimated absorbed doses to normal liver between 100 and 150 Gy. The purpose of the study was to see whether predictions of normal tissue complication probability (NTCP) models for liver based on clinical data from external beam therapy are consistent with clinical results of SIR. Liver NTCP was calculated using a parallel architecture model and normal liver dose-volume histograms that have been proposed for SIR. A parallel model including internal functional subunit structure is also proposed. Dose rate effects are incorporated. A criterion for comparing model calculations with clinical data is presented. For the parallel architecture model, the predicted NTCP is sensitive to the dose distribution in normal liver and to the model parameters, particularly the repair time. With reasonable assumptions about the microsphere distribution, the parallel model with parameters deduced from external beam therapy outcome analysis is consistent with the observed lack of liver complications. Inclusion of FSU structure widens the range of assumptions under which consistency is found. The parallel model can be consistent with the clinically observed lack of liver complications in SIR. More information about the activity distribution and the radiobiology of normal liver under conditions typical of microsphere therapy should be sought.

Importance of the redox state in vasoconstriction induced by adrenaline and serotonin.

The actin myosin system and the redox state have been implicated in a number of cellular functions and in many pathological conditions. To study the predictions of a new redox theory of actin-myosin interaction we examined the relationship between the redox state and vasoconstriction of rat aorta and dog basilar artery by adrenaline and serotonin. The results show that the contraction induced by these physiological agents can be inhibited and reversed by reducing agents.

Ageing and the immune response--a unifying hypothesis?

In this article we review the abnormalities in immune function which have been described in relation to ageing. It is suggested that thymic involution may not be the only underlying cause. Many similar changes can be induced by the endotoxins from the cell walls of Gram-negative bacteria. The colon is a large repository for these organism and bacterial breakdown products are found in portal venous blood. Spillover into the peripheral circulation is prevented by the hepatic Kupffer cells degrading these substances. A waning in Kupffer cell function is well documented in association with ageing and there may be spillover of endotoxins into the peripheral circulation in elderly individuals. It is suggested that such spillover of endotoxins may contribute to some of the immunological changes previously attributed to ageing.

Assessment of neutrophil function in the elderly using antibody coated polyacrylamide gel (immunobeads) and nitroblue tetrazolium (NBT) reduction as a combined test.

Neutrophil function was assessed in 35 elderly individuals (age greater than 75) and 20 normal young individuals (age 20-45) by combining ingestion of antibody coated polyacrylamide gel and nitroblue tetrazolium reduction in a single test. This test evaluates phagocytosis and metabolic integrity simultaneously and appears to be a sensitive and reliable test of neutrophil function. No significant difference was found (by using this test) between neutrophils from healthy elderly people and the neutrophils from young controls, or between the sexes in either age group.

Macrophage migration inhibition factor (MIF): reducing the variables.

While the phenomenon of macrophage migration inhibition is a useful indicator of lymphokine release, it may be caused by other substances, it is subject to considerable variability, and it may be masked by the concomitant presence of substances stimulating migration. We have investigated certain aspects of the lymphokine macrophage interaction in order to circumvent these problems. Cells from the murine macrophage cell line RAW 264-7 migrated with less variability than fresh guinea pig peritoneal macrophages and were more sensitive target cells for human macrophage migration inhibition factor (MIF). Assays were performed with serum-free and endotoxin-free medium and in all cases in the presence and absence of L-fucose. This added specificity to the assay in that biological MIF activity was invariably blocked by L-fucose whereas migration inhibition produced by antigen complexed antibody, endotoxin, and periodate was not affected by L-fucose. It was also possible to demonstrate MIF activity in mixtures of MIF and migration stimulation factor by using L-fucose. We suggest that MIF activity is determined with less variability by using a macrophage cell line as indicator cells and performing the assays in the presence and absence of L-fucose.

Dose distribution following selective internal radiation therapy.

Selective Internal Radiation Therapy is the intrahepatic arterial injection of microspheres labelled with 90Y. The microspheres lodge in the precapillary circulation of tumor resulting in internal radiation therapy. The activity of the 90Y injected is managed by successive administrations of labelled microspheres and after each injection probing the liver with a calibrated beta probe to assess the dose to the superficial layers of normal tissue. Predicted doses of 75 Gy have been delivered without subsequent evidence of radiation damage to normal cells. This contrasts with the complications resulting from doses in excess of 30 Gy delivered from external beam radiotherapy. Detailed analysis of microsphere distribution in a cubic centimeter of normal liver and the calculation of dose to a 3-dimensional fine grid has shown that the radiation distribution created by the finite size and distribution of the microspheres results in an highly heterogeneous dose pattern. It has been shown that a third of normal liver will receive less than 33.7% of the dose predicted by assuming an homogeneous distribution of 90Y.

Lymphokine responses to mitogenic and antigenic stimulation. Predictive value in renal transplantation.

Immune responsiveness of recipients of renal transplants from cadaver donors was monitored by measuring lymphokine responses to specific (donor antigen) and nonspecific (concanavalin A (Con A)) stimuli. Production of migration inhibition factor (MIF) in response to stimulation by Con A before and 3 days after transplantation correlated strongly with graft rejection and production of migration stimulation factor (MSTF) with graft acceptance. This pattern continued at later time intervals but was more variable. An initial vigorous MIF response to donor cell extract was associated with rejection but subsequent responses to donor extract in the 1st month after transplantation were variable and not predictive of the outcome. In some cases, there was clearly a dissociation of lymphokine responses to donor-specific and nonspecific stimuli.

Environmental sensitivities: prevalence of major symptoms in a referral center: the Nova Scotia Environmental Sensitivities Research Center Study.

Although the phenomenon of environmental sensitivities (ES) has no clear etiology nor well-accepted pathophysiology, affected individuals experience symptoms that cause varying levels of dysfunction. Through a dedicated, government-funded research and treatment center, a detailed questionnaire covering 217 symptoms in 13 systems was mailed in 1997-1998 to 812 individuals referred to the center by physicians. A total of 385 (47%) questionnaires were returned, and data were analyzed on 351 individuals. Participants tended to be women (80%), middle-aged individuals (37% age 40-49 years), and those in higher educational groups (28% completed university), but there was wide variation in demographic variables. General symptoms such as difficulty concentrating, fatigue, forgetfulness, and irritability dominated the overall prevalence of symptoms since the start of their illness. Those related to irritation such as sneezing, itchy or burning eyes, and hoarseness or loss of voice were more common after exposure to environmental irritants. Ranking of symptoms using severity scores was consistent between men and women. Overall scores were higher in women, in participants who were separated or divorced, and in low-income groups. The type and consistency of symptoms experienced after exposure to triggering substances may not fit a purely psychogenic theory.

Use of goal attainment scaling in measuring clinically important change in the frail elderly.

The selection of appropriate outcome measures is important in evaluating specialized geriatric programs, but how the various measures compare, and which are most appropriate, are matters still largely unexplored. We compared several outcome measures, including goal attainment scaling, to assess their sensitivity to changes in the health status of frail elderly patients admitted to two geriatric medicine wards. GAS is a measurement approach which accommodates multiple individual patient goals, and has a scoring system which allows for comparisons between patients. Forty-five patients (mean age 81 years, 30 females) received comprehensive assessments. GAS yielded a mean 5 goals per patient. The mean gain in the GAS score was 22 points (SD = 7) which was compared with the change in the Barthel Index (r = 0.59), the Functional Independence Measure (r = 0.45), the Physical Self-Maintenance Scale (r = 0.54), the Katz Activities of Daily Living Index (r = 0.49) and the Spitzer Quality of Life Index (r = 0.38). The inter-rater reliability of scoring the GAS follow-up guides was 0.91. Using a relative efficiency statistic, GAS proved more efficient than any other measure. The effect size statistic also demonstrated an increased responsiveness to change of GAS compared with standard measures. GAS is an individualized measurement approach which shows promise as a responsive measure in frail elderly patients.

The use of goal attainment scaling in a geriatric care setting.

OBJECTIVE: Goal attainment scaling (GAS) is a measurement approach used extensively in mental health. It accommodates multiple individual patient goals, yet retains mathematical properties allowing comparisons between patients. This study was carried out to investigate the feasibility and measurement properties of GAS in a geriatric care setting. DESIGN: Prospective descriptive study. SETTING: The geriatric restorative care service and geriatric assessment unit at Camp Hill Hospital, a 350-bed tertiary care facility in Halifax, Canada. PATIENTS: Fifteen patients aged 65 to 94 who were consecutively admitted to the two geriatric services (mean age 79 years, mean length of stay 37 days, 9 females). INTERVENTION: Goal Attainment follow-up guides were developed independently for each patient by two geriatricians after a comprehensive assessment of the patient. These guides were later compared to assess level of agreement in goal setting and scale development. A single goal attainment follow-up guide was then developed for each patient by consensus of the two geriatricians. At the end of the follow-up, the guides were scored independently for each patient by one of the geriatricians and by the patient's primary care nurse. MAIN OUTCOME MEASURES: GAS scores were determined on admission and discharge. Each patient also received admission and discharge ratings on the Barthel Index as well as a global rating of outcome (on a subjective 10-point scale) by a geriatrician who was blinded to the Goal Attainment follow-up score. RESULTS: GAS proved feasible, requiring 15-20 minutes to scale an average of six goals per patient. GAS also appears reliable. Of 87 goals, 71 (82%) were identified independently by two geriatricians, and the remainder were determined by consensus. This is also a measure of content validity. The physician-nurse inter-rater reliability was 0.87 (intraclass correlation). Concurrent validity was assessed by correlation with the Barthel Index (r = 0.86) and the global clinical outcome rating (r = 0.82). Content validity was also assessed by comparing our goal areas with those identified in recent consensus reports on geriatric assessment. Of these 13 assessment areas, 12 appeared to be reasonably well covered while one assessment area (sexual problems) was not identified for any of the 15 patients. CONCLUSIONS: GAS appears to be a feasible method of goal setting and outcome evaluation in geriatric care settings, with promising reliability and validity.

Gynecologic sepsis as a cause of covert infection in old age.

Three cases of endometritis, which presented covertly in elderly women, are described. All three patients were in a poor state of nutrition, and two had serious intercurrent disease. It is believed that cyclical shedding of the endometrium and "normal" vaginal flora (under the influence of estrogen) are the major defenses against infection. These are lost after the menopause, and were therefore absent in the three patients described here. The waning of the immune response associated with aging, particularly the progesterone-stimulated uptake of polymeric IgA in the endometrium, may be important, as may the immunosuppressive effect of malnutrition. It is suggested that a nonspecific deterioration in an elderly woman or infection of uncertain site should prompt a careful re-examination, including a thorough pelvic examination.

The white nails of old age (neapolitan nails).

Nail changes similar to those reported by Terry and Lindsay were defined in an elderly inpatient population. Two hundred fifty-eight patients were studied, and an overall incidence of 19 per cent was found. There was no significant difference between men and women. The only significant correlations in this study were with osteoporosis and thin skin. Eight men with nail changes were compared with seven men without such changes by calculating the metacarpal index of cortical bone mass. The index was much lower in patients with nail changes (t = 2.64; P less than 0.01). All patients with nail changes had thin skin. No correlations were found with serum albumin, liver function, or kidney function. These nail changes are less frequent in the "less frail" elderly living in the community. Changes of the Terry type are common in children but disappear by early adult life. It is suggested that the nail changes are age-related phenomena and that they may reflect an underlying disturbance of collagen being manifested as changes in the nail bed, skin, and bone.

The frequency of physical signs usually attributed to meningeal irritation in elderly patients.

Nuchal rigidity, which may be a sign of meningitis, was found in 35 per cent of geriatric patients on acute-care and rehabilitation wards and in 13 per cent of younger patients on an acute-care ward. It was significantly associated with cerebrovascular disease, confusion, abnormal plantar responses, and primitive reflexes. Elderly patients who have nuchal rigidity with no history of neurologic or cognitive disorders should be investigated for meningitis.

Light microscopic image analysis system to quantify immunoreactive terminal area apposed to nerve cells.

The present report describes a desktop computer-based method for the quantitative assessment of the area occupied by immunoreactive terminals in close apposition to nerve cells in relation to the perimeter of the cell soma. This method is based on Fast Fourier Transform (FFT) routines incorporated in NIH-Image public domain software. Pyramidal cells of layer V of the somatosensory cortex outlined by GABA immunolabeled terminals were chosen for our analysis. A Leitz Diaplan light microscope was employed for the visualization of the sections. A Sierra Scientific Model 4030 CCD camera was used to capture the images into a Macintosh Centris 650 computer. After preprocessing, filtering was performed on the power spectrum in the frequency domain produced by the FFT operation. An inverse FFT with filter procedure was employed to restore the images to the spatial domain. Pasting of the original image to the transformed one using a Boolean logic operation called 'AND'ing produced an image with the terminals enhanced. This procedure allowed the creation of a binary image using a well-defined threshold of 128. Thus, the terminal area appears in black against a white background. This methodology provides an objective means of measurement of area by counting the total number of pixels occupied by immunoreactive terminals in light microscopic sections in which the difficulties of labeling intensity, size, shape and numerical density of terminals are avoided.

Effect of copper sulphate on the rate of afferent discharge in the gastric branch of the vagus nerve in the rat.

The afferent nerve activity was recorded from a nerve filament isolated from the peripheral cut end of the gastric branch of the vagus nerve. The gastric perfusion of 4 ml of two different concentrations (0.04% and 0.08%) of CuSO4 solution provoked an increase in afferent activity. The stimulating effect of the 0.08% solution was stronger than that of the 0.04% solution, and lasted for a longer period of time. The observations suggest a possible mechanism by which CuSO4 elicits emesis.