Y. Jaber

The Diagnostic and Prognostic Performance of a Selective Screening Strategy for Gestational Diabetes Mellitus According to Ethnicity in Europe

CONTEXT The performance of standard selective screening strategies for gestational diabetes mellitus (GDM) may vary according to ethnicity. OBJECTIVE We aimed to evaluate the diagnostic and prognostic performance of a selective screening tool to determine whether it accurately predicts GDM and events in women of different ethnicities. The tool selectively screens based on patients having one or more of the following risk factors (RFs): body mass index ≥25 kg/m(2), age ≥35 years, family history of diabetes, and personal history of GDM or macrosomia. DESIGN AND SETTING We conducted an observational prospective study at a university hospital. PARTICIPANTS We included 17 344 women of European (30.9%), North African (29.6%), Sub-Saharan African (22.2%), Caribbean (8.7%), Indian-Pakistani-Sri Lankan (5.5%), and Asian (3.3%) ethnicities who were without pregravid diabetes and had singleton deliveries (2002-2010). MAIN OUTCOME MEASURES We universally screened GDM and GDM-related events (pre-eclampsia, birth weight ≥4000 g, or dystocia). RESULTS Independent of confounding factors, North African (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.21-1.52; P < .001) and Indian-Pakistani-Sri Lankan (OR, 2.52; 95% CI, 2.13-3.00; P < .001) women had more GDM than Europeans, whereas Sub-Saharan African women had less (OR, 0.82; 95% CI, 0.71-0.94; P < .01). Having one or more RFs was associated with GDM among Europeans (OR, 1.45; 95% CI, 1.22-1.76), North African (OR, 1.33; 95% CI, 1.13-1.55), Sub-Saharan African (OR, 1.48; 95% CI, 1.20-1.83), and Caribbean (OR, 1.55; 95% CI, 1.12-2.14) women. Having one or more RFs was also associated with GDM-related events only in European (P < .01) and North African (P < .05) women, with the following incidences in Europeans: no GDM/no RF, 6.9%; no GDM/RF, 9.0%; GDM/no RF, 14.7%; and GDM/RF, 12.6%. CONCLUSION Standard selective screening criteria were not predictive of GDM in women from India-Pakistan-Sri Lanka and Asia and were associated with GDM-related events only in European and North African women. However, the women with GDM, who were routinely treated, had a poor prognosis, even for those free of RFs. These results support universal screening, irrespective of ethnicity.

Glycation Gap Is Associated With Macroproteinuria but Not With Other Complications in Patients With Type 2 Diabetes

OBJECTIVE We investigated whether glycation gap (G-Gap), an index of intracellular glycation of proteins, was associated with diabetes complications. RESEARCH DESIGN AND METHODS We measured concomitantly HbA1c and fructosamine in 925 patients with type 2 diabetes to calculate the G-Gap, defined as the difference between measured HbA1c, and fructosamine-based predicted HbA1c. Patients were explored for retinopathy, nephropathy, peripheral neuropathy, cardiac autonomic neuropathy (n = 512), and silent myocardial ischemia (n = 506). RESULTS Macroproteinuria was the only complication that was associated with G-Gap (prevalence in the first, second, and third tertile of G-Gap: 2.9, 6.2, and 11.0%, respectively; P < 0.001). The G-Gap was higher in patients with macroproteinuria than in those without (1.06 ± 1.62 vs. 0.03 ± 1.30%; P < 0.0001). Because HbA1c was associated with both G-Gap (HbA1c 7.0 ± 1.4, 7.9 ± 1.4, and 10.1 ± 1.8% in the first, second, and third G-Gap tertile, respectively; P < 0.0001) and macroproteinuria (HbA1c 8.8 ± 2.2% if macroproteinuria, 8.3 ± 2.0% if none; P < 0.05), and because it could have been a confounder, we matched 54 patients with macroproteinuria and 200 patients without for HbA1c. Because macroproteinuria was associated with lower serum albumin and fructosamine levels, which might account for higher G-Gap, we calculated in this subpopulation albumin-indexed fructosamine and G-Gap; macroproteinuria was independently associated with male sex (odds ratio [OR] 3.2 [95% CI 1.5–6.7]; P < 0.01), hypertension (2.9 [1.1–7.5]; P < 0.05), and the third tertile of albumin-indexed G-Gap (2.3 [1.1–4.4]; P < 0.05) in multivariate analysis. CONCLUSIONS In type 2 diabetic patients, G-Gap was associated with macroproteinuria, independently of HbA1c, albumin levels, and confounding factors, suggesting a specific role of intracellular glycation susceptibility on kidney glomerular changes.

P112 Un algorithme de gestion des diabétiques en garde à vue : Une initiative attendue

Introduction La forte augmentation de prevalence du diabete et des gardes a vue rend compte des difficultes croissantes rencontrees par les medecins et le personnel lors des gardes a vue au commissariat qui durent au maximum 48 heures. Nous proposons ici pour la premiere fois un algorithme de prise en charge de ces patients. Resultats Un medecin doit systematiquement examiner les diabetiques aux urgences medico-judiciaires (UMJ), avec mesure de la glycemie capillaire. Une baisse d’acuite visuelle recente, une plaie du pied et des douleurs thoraciques atypiques ou equivalents doivent conduire a une prise en charge aux urgences immediate, tout comme une glycemie capillaire > 2,5 g/l associee a une cetose. Les diabetiques sont classes selon qu’ils sont insulino-traites (risques majeurs des DIT : hypoglycemie, acido-cetose surtout si diabete de type 1) ou non (risques majeurs des DNIT : hypoglycemie sous insulino-secretagogue (IS), coma hyper-osmolaire). En cas d’hypoglycemie, le resucrage est immediat (equivalent de 15 g de glucides) ; la surveillance glycemique doit etre prolongee sur plusieurs heures, en raison de la demi-vie des traitements ; chez un DIT, une insulinotherapie basale doit etre poursuivie alors que les anti-diabetiques oraux sont arretes en cas de DNIT. Dans les autres cas, le patient peut retourner au commissariat. Chez le DIT, une insulinotherapie basale est prescrite, associee a une insulinotherapie prandiale. Chez un DNIT, le traitement anti-diabetique oral est arrete si la glycemie est entre 0,7 et 1,5 g/l, et poursuivi dans les autres cas. La prise de boissons non sucrees doit etre libre et des repas doivent etre servis. Discussion L’evaluation prospective de cet algorithme montre des resultats encourageants. Une consolidation de formation sur les insulines et les IS est necessaire. Conclusion Un algorithme de prise en charge des diabetiques en garde a vue aidera les soignants, en prenant en compte en particulier les specificites cliniques, les risques encourus selon l’insulinotherapie ou non, avec des recommandations sur la poursuite et/ou l’adaptation du traitement, l’alimentation et la prise de boissons, la surveillance.